Healthcare
Insurance Review

A Healthcare Insurance Review is a valuable tool to help both parents and insurance companies. Sometimes when children are ill or injured and, in the hospital, the insurance company denies payment for treatments considered experimental or not mainstream medicine. This process gets handled by the in-hospital utilization review staff and can be escalated up to the medical director of the insurance company. A step beyond the medical director is to request independent external review.

The decisions internal to the insurance company are often made by nurses employed by the insurance company and via algorithms internal to the insurance company. Often these are driven by adult literature that may not always have pediatric applications.

Beyond the medical director of the insurance company the family can request an external, independent review. The insurance company may also request this when they are pursuing an overabundance of caution. This independent reviewer will review all the facts of the case as well as the internal algorithm and the pertinent medical literature. They will then advise if the internal insurance algorithm is commensurate with the scientific data and after reviewing all the facts of the case they can:

1. uphold the insurance decision, 
2. partially uphold the decision or
3. overturn the insurance decision.

This will be the final step in the payment process.

Pediatric Medical Experts has been able to conduct thorough healthcare insurance reviews and provide research-based, up-to-date and cutting-edge opinions on current medications, procedures, and treatments. We then interact with the insurance company on the patient’s behalf to help bring understanding and agreement, which may save the child’s life.

As a result of helping to educate the insurance company, the parents may then be able to get the insurance company to provide the coverage needed so that their child can receive the necessary treatments or therapies.