Questions Prospective Cochlear Implant Appeals Clients Should be Asking OMS
How many policy changes, insurance commissioner rulings, and external reviewer rulings does OMS have for your type of appeal?
The Let Them Hear Foundation Advocacy Program has been responsible for:
- Ten different insurers changing their policies to include bilateral cochlear implantation as a standard coverage benefit, affecting over 158 million people,
- Twenty-two different rulings from eleven different state insurance commissioners,
- Over thirty other positive external reviewer rulings,
- Over fifty oral arguments resulting in coverage for the patient, and
- Several positive administrative law judge rulings for federally managed plans
What percentage of OMS’ total cases are like yours?
OMS claims they are projecting 600 cases in the next year. However, this figure likely includes initial authorization requests and Medicare processing for replacement cables and batteries. The Let Them Hear Foundation ONLY does appeals, therefore, our total number of cases (over 700) represent only appeals, of which about 70 % relate to cochlear implants.
How much of my appeal will be personalized?
Insurers can “smell” a cookie-cutter appeal. Appeals where the name of the insurer and the name of the patient are the only thing that is different are generally less successful than appeals that argue specifically why the patient should be entitled to a particular service.
Every Foundation appeal includes an in-depth review of your medical situation including review of outside medical records and records associated with school performance to write an appeal that is about you. In addition, Foundation staff will assist you in writing any material that you wish to include with your appeal. Every appeal is customized for your particular situation, whether that is an unusual source of hearing loss, or a complicating medical condition.
Does OMS personnel have personal experience with hearing impairment?
Several of the Foundation’s advocacy program personnel are hearing impaired or have children who are hearing impaired. Our passion for championing the cause of services for the hearing impaired derives from this personal impact, not a paycheck or corporate profits.
How much experience does OMS have doing insurance appeals like yours?
The Foundation’s program consists of entirely trained legal professionals – three full-time fully licensed attorneys, a law school graduate with eleven years of hearing impairment appeal related experience, a licensed paralegal, and four part time law students. We do not use reimbursement or billing personnel. The Foundation only brings in outside legal assistance to file court paperwork in local jurisdictions.
How does OMS intend to counter the argument that Cochlear will benefit financially from the approval of the requested service?
Insurance companies and medical directors are frequently just looking for a legitimate excuse to hang their denials on. OMS hands them the excuse they are looking for from the outset by having a financial interest in the outcome of the appeal, because every appeal win results in a device sale for Cochlear. Even though, regrettably, the Foundation must charge patients who wish Cochlear devices for our services, our financial interest ends there and is not tied to the outcome of the case.
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