Understanding Insurance Denials for Pediatric & Newborn Care: A Parent's Guide to Fighting Back

social0044
Jun 25
2 min read

Updated: Jun 26

What are the most common insurance denials parents face with newborn care?

Insurance companies often create complications during the process of adding newborns to health insurance policies. Parents frequently encounter issues when adding their newborn to either or both parents' policies. In the first 30 days, newborns should automatically be covered under the parent's policy, but insurance companies often look for technicalities to deny claims. A significant issue occurs with Affordable Care Act plans, where the marketplace sometimes accidentally disenrolls parents while adding newborns, creating administrative chaos that requires litigation to resolve.

What specific coverage challenges do children with autism face?

Children with autism face particular challenges in securing coverage for various necessary therapies, including physical, occupational, speech, and behavioral modification therapy. Insurance providers, whether Medicaid or private insurers, often find technicalities to deny these essential services. In Florida, while laws require employer group plans to provide certain coverage amounts, denials often occur based on provider qualifications or diagnostic technicalities, overriding behavioral providers' recommendations.

How do insurance companies handle growth hormone therapy coverage?

As medical advances allow doctors to better identify growth deficits and developmental issues, insurance companies often create barriers to accessing new hormone therapies. They typically require children to fit strict criteria, using a "checkbox" approach that doesn't account for individual medical needs. This standardized approach often conflicts with the medical standard of care, as each child's situation is unique.

What steps can parents take when facing insurance denials?

The appeals process typically involves multiple steps:

Initial appeal through the doctor's office
Peer-to-peer review with a specialist of the same level
First level appeal
Second level appeal
External review

Each level has specific deadlines and requirements. For Medicaid cases, the process includes two appeal levels followed by a fair hearing with a hearing officer.

How can parents work with physicians to build a strong case?

Legal teams work closely with physicians to gather comprehensive medical documentation, including medical records, physician letters, and affidavits. In some cases, doctors may testify in court or Medicaid hearings to support their patients' needs. This collaboration between legal and medical professionals is crucial for successful appeals.