Health insurance claim denied - now what?

[Poppy]

My health insurance has denied a claim for a blood test, submitted through a lab. They said they did not receive sufficient documentation showing that the test was medically necessary, so the lab got some medical records from my doc and resubmitted the claim. I just received notice that the review is complete and they are still not paying (but no further details).

So what are my next steps here? I am pretty ticked off that they would not cover it. I am not in the 'typical' population that's usually covered (the website for the test specifically says that my insurer is in-network for it) BUT I have a history of the problem and the ACOG (professional org for OBGYNs) has issued an "opinion" that the test is indicated when there is prior history. Also, my doc recommended it (obvs) and she says she thinks it should be covered.

Do I have any recourse? I am trying to keep this brief but I can add more detail if needed.

[Deleted]

1) You can have your doctor call directly. My DH (a physician) does this all the time.

2) You can appeal to your state department of insurance. Most have rules regarding insurance denials and what your rights are in these situations. They may be able to mediate on your behalf.

[mich1]

Contact your insurance company and get the information as to who you need to contact to write an appeal letter. You might want to also include any documentation you have about the necessity of the test. This is important, so you might want to contact your doctor for something written on his letterhead to help you out.

I got really good at writing appeal letters trying to get things covered. The last 2 years, I must have needed to write around 8 letters to my insurance company board of appeals to get services covered that I felt should have been covered. I had a 100% success rate in getting them covered.

My insurance company took 6-8 weeks to review, so make sure that you contact the lab and let them know that it's under appeal. They may require you to pay (to avoid getting sent to collections - and they WILL do this), but if your insurance company antes up the $$, they'll send you your money back.

[Poppy]

Thanks mich1. I am a little concerned about this because they already did a review and I'm not sure they'll do it again.



After the initial denial, I brought a compilation of evidence to my doctor (referencing the literature showing increased risk of recurrence, referencing the ACOG guidelines, and outlining my history) and she was all, "You didn't have to do a lit search! There are dozens of studies backing up this recommendation, believe me, I know, I give talks on this. I will have the rep take care of it." But of course that kind of takes it out of my hands - she supposedly contacted her rep (I believe a sales person who promotes the test) but I have no idea if anything happened because of that. I also called the lab because the bill was due, and they told me they would "pause the clock" on the bill and handle resubmitting the claim. That's what started the review.

I was getting a different story from everyone and my husband told me to trust the doc and not pursue the appeal myself, now I'm kicking myself. Ugh. I will call the insurer though and see if there's anything else I can do.

[mich1]

I was lucky when I started to need to write letters of appeal because my issues were such that I wound up with a case worker that helped me navigate through things (both medical issues and dealing with insurance). She explained to me exactly what I needed to say in the letters (in my case, it was getting a physician's services covered when the physician was contracted to work in an in network facility, even though his practice was not in network).

Maybe there is someone like this available for you?

[aurora]

Do you have an insurance advocate through your company (or H's, whichever provides your health insurance)? We do, but it's not well-publicized. She is available to help employees navigate the insurance system, including figuring out how to go about appeals (not giving legal advice or anything, but rather helping you get connected to the right person in the system).

At a bare minimum, you are entitled to an explanation of why your claim was denied. If it's still insufficient information, then get someone to tell you exactly what information is needed.

[Poppy]

Aug 28, 2014 15:08:05 GMT -5 aurora said:

Do you have an insurance advocate through your company (or H's, whichever provides your health insurance)? We do, but it's not well-publicized. She is available to help employees navigate the insurance system, including figuring out how to go about appeals (not giving legal advice or anything, but rather helping you get connected to the right person in the system).

At a bare minimum, you are entitled to an explanation of why your claim was denied. If it's still insufficient information, then get someone to tell you exactly what information is needed.

Another complication - I switched jobs a month ago and my insurance was through my old company. I'm hoping this doesn't hurt me in terms of their willingness to pay.

It's possible that my old company would still help me... I'll have to get some contact info from my friends who are still there. Thanks for the tip though, I hadn't thought of that.

[babsbunny]

Not sure how related this would be... Dentist gave DH a full x-ray many years ago, but it was within 2 years of the last x-ray he had gotten so we got a bill. I called and made the dentist pay for it because they did not ask us to approve the charges ahead of time. The dentist paid for it.

Additional information... The dentist specifically did not do my full x-ray because they spoke to my insurance and found I wasn't covered for another year. I asked them to pay for DH's bill because I assumed they would have done the same insurance check.

I once asked our PCP's receptionist flat out how much a simple physical with heart check would cost the husband and they could not tell me. It's impossible to shop around for prices when no one knows how much someone will be charged!

If the doctor recommended a procedure, have them pursue it, and in the meantime, ask them to foot the bill.

[audry80]

Not the same but I had a prescription denied by my insurance company. It was denied three times before they finally agreed to pay for it. My Doctor was the one who initiated all the appeals. Good luck, I hate dealing with insurance Crap.

[mskitkat]

Good luck. I had a very similar problem. My doc provided all sorts of information why it was medically necessary, but the insurance company still denied it all the way through final appeal.