In this episode of Fix My Claims Podcast, Mary Covington discusses how to navigate denied insurance claims. Tune in to learn the steps Mary uses to fight claim denials, understand your policy, and secure your rightful benefits. 

Whether dealing with medical, dental, or disability claims, this episode offers essential tips and strategies to help you tackle insurance roadblocks and get the compensation you deserve. 

Don't miss out on valuable advice that can save you time and money.

[00:00:24] Mary Covington: I actually moved from New York to Idaho when I was 14, and I ended up in Salt Lake City, and I lived down the block from a guy that was the director of Aetna Life and Casualty in Salt Lake City. And so, he offered me a job, I had wanted to go to law school. So, I took the job at Aetna.

[00:01:08] Chris Farrell: Love it. And then, how many years have you been in the claim industry?

[00:01:48] Mary Covington: The insurance industry is one where you will get a denial. We're all going to die someday, and in life, if you get sick, you're probably going to end up fighting a denial at some point. [00:02:00] The insurance company is going to say, Oh, it's not medically necessary, it's not covered. We don't like that provider, they're not in your network. There's all kinds of things that occur with claim denials, but it's easy to identify one because they don't pay. Then you get a bill from your doctor or your hospital.

[00:02:42] Chris Farrell: I can just tell that you're such an advocate for your clients. So, let's play out a fun little scenario here, okay? Let's say, people can listen to all different types of podcasts. But let's say, somebody just got in the mail, word, that they have a claim's denial. And they are so confused, and there's so [00:03:00] much complexity behind this idea of, how do I actually acquire the result I'm looking for, in terms of getting the money back? With that being said, what is in it for a listener, listening to the FixMyClaims podcast?

[00:03:50] Mary Covington: So, many people don't understand that process of, how do I check to see if my claim is valid and should [00:04:00] be paid? Many people will pick up the phone and call the insurance company, that may not always be the right thing to do first. Generally, you want to understand the type of denial and check your insurance policy. If they say, it's not covered, you want to go look at the exclusions in your plan.

[00:04:55] Chris Farrell: That's really good. That's really helpful because I think a lot of times, like you mentioned, [00:05:00] this isn't something that they teach us in school. And so, being able to have a show like this podcast where, Hey, I have this problem, this is a real problem. I am feeling like, I don't have the time to navigate the complexities of this world, I don't know where to go first. You're already giving us value with what you just said.

[00:05:32] Mary Covington: I find that having played a lot of games when I was growing up, I have 5 brothers and 3 sisters. And so, games are an important part of my strategy. So, there's always a way to win any game, I play hearts on my computer, and I play solitaire on my computer. And so as I'm playing, I'm strategizing how I'm going to win.

[00:06:22] Mary Covington: And so, along with that comes all the laws, the rules, the regulations, the insurance policy, the reason they denied, what type of policy you have? How many appeals you've got? And then, you begin to build your evidence to pursue that claim.

[00:06:46] Mary Covington: I feel like I grew up in claims, as I got older and the more claims I did, new federal laws came in. So, it's new and exciting, there's always something new in claims or there's a new [00:07:00] reason an insurance company denied, and I'm like, what? And so, you begin to check everything, it's that ability to create the strategy from everything that you've learned over 53 years.

[00:07:36] Mary Covington: And we're all going to get sick at some point. So, the issue becomes, how do I make it? I'm insulated from an insurance company denial that we believe is valid. And so, that strategy comes from all of these things that we've done over the years, working with attorneys, reading court opinions.

[00:08:12] Chris Farrell: Sure. So, what is the result of somebody who receives word that they've had a denied claim? What's the result of someone who has gotten a denied claim and they just like, kind of act like it doesn't exist? And they just push the mail off and then they get more mail. And they're like, I know I need to solve this problem, but I just don't have time to do it.

[00:08:51] Mary Covington: You need to work on it immediately. And the rule is, you generally only have 180 days to appeal [00:09:00] and gather up all that evidence. So, you don't want to wait till the last minute. Because your strategy begins right at the beginning so that you can make sure that all of the evidence is in the file, and you can write a great appeal letter that is going to get you a win and an overturn.

[00:09:28] Mary Covington: Most attorneys are equipped to litigate, they don't generally do appeal work. We get a lot of referrals from attorneys to help families, because their work is much more expensive than ours, obviously, because they're attorneys. So, being a healthcare advocate, it gives you that ability to know everything that the attorneys know and work with the attorneys to make sure that, again, your appeal strategy is solid as it pertains to the regulations, or [00:10:00] state laws, or the policy itself.

[00:10:26] Mary Covington: And most of them are taken and they love our work. They think that we are the solid people that know how to write a solid appeal. Some of our medical necessity appeals are 100 pages with 5,000 pages of evidence and 42 exhibits. And you want to make sure that when you are going in for a win, that you've checked all the boxes of the arguments that you want to make.

[00:11:19] Chris Farrell: So, Mary, you mentioned 53 years. I'm sure you have some bizarre stories. Do you have any particular story that you would share with us? That would give us some insight into, where someone is at, and how you can help.

[00:11:59] Mary Covington: And that is [00:12:00] actually in a letter. Sometimes I almost fell off my chair, but I was shocked to learn that an insurance company would do that. I had a guy in Florida years ago that was working for Tollman-Hundley Hotels and he and an employee were spraying water on each other. And the woman came out and fired them for doing that, and so he took off on his motorcycle and he hit a car, and he became a quadriplegic.

[00:13:02] Mary Covington: He was fired for gross misconduct. And I said a water hose is a gross misconduct? I don't think so. So, we began an appeal and helped Mr. Kuhn because he needed a wheelchair, he needed a specialized bed. There was so much equipment that he was going to need in his life, and the care he needed just to become independent was going to be months and months of treatment.

[00:14:16] Mary Covington: This is the craziness that goes on in this industry, and it never ceases to amaze me what we see on a day-to-day basis, and how inept right now the insurance companies are. Services is at an all-time low, we're on the phone when we call them for 2 hours, who can do that? Who can sit on a phone for 2 hours waiting for somebody to pick up and give you an answer? So, there are things going on in this industry that totally suck. And my goal is to try to fix some of it, but it's one claim at a time. And so, there's got to be more help from Congress. There's got to be more help from the [00:15:00] Department of Labor. And so, one of the things is, I'm going to talk to them in the next few weeks.

[00:15:27] Mary Covington: And they're hiring people that know nothing. They don't know how to speak the language of claims. And it's very frustrating for a family that knows nothing to get on the phone with these people, and try to get a good answer instead of being shuffled off. I can call an insurance company on a claim 10 times, and I'll get 10 different answers, or each time I call, they'll say, Oh, the claims in process, that's their pat answer. Oh, it's being worked. Oh, I sent it back, but it didn't [00:16:00] get there. So now, I'm going to resend it. How many times are you going to let them get away with that without making a complaint somewhere to someone?

[00:16:21] Mary Covington: I think it just fell in my lap, and when I realized that I had more knowledge about claims than anyone else I'd met in my life after 20 years. When I left the insurance industry and moved to the hospital, the physical medicine and rehab hospital where traumatic brain injuries, spinal cord injuries, strokes, and multiple traumas, these were real people to me. When you're just looking at paper, but I was in the hospital setting, and I was meeting the families, and I was talking [00:17:00] to them, and I was feeling their pain, and seeing the struggle of what it was like to be in that type of situation?

[00:17:43] Mary Covington: And so, to be able to be that voice, be that person that could walk them through it and take away that stress, and make it be more of a process, and give them peace of mind. [00:18:00] Yes, we're going to win, we'll win. And if I don't win, I've got somebody who will litigate this case for you.

[00:18:34] Chris Farrell: So, Mary, when it comes to a denied claim, what are the repercussions for completely ignoring it and not dealing with it?

[00:19:05] Mary Covington: And then, it's just that feeling of helplessness that you can't fix it. You gotta have somebody that was is in your corner to help you fix it. And I've done it in my life before, like my taxes, I don't want to do my taxes, I hate taxes. But yet I know I gotta do them and my tax man's, where's your stuff?

[00:19:40] Mary Covington: So, you just need good advice, you need that kind of thing. People around you that know what's going on. So, I guess, it's looking for someone with experience that is well-versed in what you need.

[00:20:05] Mary Covington: There are people who attempt to do it on their own. And sometimes, they come to me and I'm just like, okay, that was an effort. It wasn't the best effort you could have done, some people will write 3 paragraphs to their insurance company, or they'll call them and say, do you want to appeal it? Yeah, I want to appeal it.

[00:20:47] Mary Covington: And some of them are just, it's not covered. And so, you need more information, and families just don't understand how important it is not to do those types [00:21:00] of things. Don't do it on your own, if you do, you're not going to get anywhere, and you're going to get more frustrated because you're just going to keep getting nos.

[00:21:34] Mary Covington: And it's learning podcasts, there's a process that you go through and you just got to learn to do it. And so, I think some people are built for it and some people are not. And they're more of the wringing hands type. So, you've got to know what your personality is, what type you are, and then, am I a go-getter? Can't do I think I can do it, but I still wouldn't do it without some advice.

[00:22:18] Mary Covington: So that I can give you some free advice, even if you don't want to come with me, at least let me give you a little guidance. So, I haven't heard back from her yet, but I'm hoping I will today. So, some people, they want something for nothing, which most people do anyway, but you got to get in, and you got to dig in, and generally will need some guidance in doing this.

[00:22:57] Mary Covington: I think if they go to our website, [00:23:00] FixMyClaim.com, there is an inquiry where you can reach out to us. And I believe, we automatically schedule a call with the family. And there's a place to put a little bit of information about your claim. And so, that opportunity to talk to the family, it's the best thing, and it gives me the opportunity to hear the story. Because every claim has a story, and that's what I like about claims, there's always a family behind it.

[00:23:49] Mary Covington: Who's the policyholder? Is it a large company or a small company? And that begins to give me what laws apply, and what rules apply. What type of [00:24:00] denial was it? Give them some information that they can feel good about and begin to understand their claim. So, their story then equates to the claim, which makes the strategy of, how you're going to go get that money?

[00:24:41] Mary Covington: And then we talk about getting the insurance policy, and doing those things that are necessary to begin the investigation work of it. Send us a copy of the denial, send us your policy, send us your ID cards, all of those things that start to begin the foundation of how to move forward to win.

[00:25:20] Chris Farrell: Now, I know what my insurance rights are. I know what things I should be looking for in terms of what an insurance company is doing that I wouldn't have seen otherwise. There's so much to share with people, and I'm so excited for the future of this podcast. Again, I'll hand it off to you from here on out on the next episode, but thanks so much for joining me for this initial pilot episode.