topic Re: I won my appeal!!!! in Community Chat

I won my appeal!!!!

hoosieroriginal — Fri, 25 Aug 2017 18:55:18 GMT

My medical insurance refused to pay my ambulance bill over a year ago when I had a kidney stone attack. They stated it was a "non-paid benefit". After I looked at my insurance benefits, I saw I had a $200 deductible for ambulance service. I immediately wrote a letter of appeal. It has taken 10 MONTHS for this process because the hospital wasn't getting my insurance company all of the medical records. The hospital kept billing me for the $3,000. I kept telling them I appealed and that it was them who was holding up payment by not getting my insurance company the medical records. Today I received yet another bill from the hospital (the last couple of months I have not received a bill because they finally got the idea it was under appeal). I called my insurance to find out the status of my appeal and she informed me I won my appeal. She told me to tell the hospital it will process the payment in several weeks. So I wrote a letter to the hospital enclosing their last statement (if you call you are on hold 45 minutes) and advising them payment would be forthcoming from my insurance company. Whoo hooooo! Moral to this story - don't stand idlely by and let insurance companies walk all over you! . It takes a lot of effort, a lot of phone calls, but it's worth the fight.

Re: I won my appeal!!!!

meallen616 — Fri, 25 Aug 2017 18:57:58 GMT

Good for you, great news,

Re: I won my appeal!!!!

chrystaltree — Fri, 25 Aug 2017 19:03:03 GMT

Good for you; when you know or even just suspect you are right, you have to go through the appeals process and it does take time and they do make you jump over a lot of hurdles but it's worth it.

Re: I won my appeal!!!!

Bri36 — Fri, 25 Aug 2017 19:05:01 GMT

It takes a lot of time and effort sometimes, but it's worth it in the end.

Re: I won my appeal!!!!

game-on — Fri, 25 Aug 2017 19:14:37 GMT

@hoosieroriginal....Congrats!

Re: I won my appeal!!!!

Vivian — Sat, 26 Aug 2017 12:08:52 GMT

I agree that it pays to fight insurance denials. Several years ago I had a surgical procedure that my insurance company refused to cover. I was asked to supply letters from three doctors saying the surgery was medically necessary. I supplied the letters but I still got a denial. I made phone calls, supplied more information, including photos and x-rays to no avail. Finally, after nine months went by, my surgeon wrote to the insurance company threatening that all ten surgeons in his practice would not accept that insurance if they rejected my claim. It worked. It took nine months, but I won, thanks to my doctor.

Re: I won my appeal!!!!

Lilysmom — Fri, 25 Aug 2017 19:43:26 GMT

@hoosieroriginal, atta girl! So glad you won🙂! LM

Re: I won my appeal!!!!

NicksmomESQ — Fri, 25 Aug 2017 19:44:10 GMT

Some years back I had an emergency procedure in my doctors office.My insurance company denied the claim stating that the procedure required pre approval. Doctors office submitted documentation to show there was no time to get prior approval.They stood by their denial.

My doctor called & insisted on speaking not to a claims person or manager but to the doctor overseeing the people who issued the denial.He got the runaround but was persistent until he spoke to the doctor in charge.

The bill was paid in full & my copay was waived !!

Insurance companies want to avoid bad publicity.If you make a fuss & have a good argument they usually pay up.

Re: I won my appeal!!!!

bonnielu — Fri, 25 Aug 2017 19:48:29 GMT

It pays to be persistent. I have a rule... I keep calling back whenever there is a problem and I finally get someone who will see it my way. Takes time but it is worth it.

Re: I won my appeal!!!!

CatLoverDogsToo — Fri, 25 Aug 2017 19:48:48 GMT

@hoosieroriginal CONGRATULATIONS!!! I am so glad for you.

Where I live, the hospital sends people to collection if the bill isn't paid in full in 30 days. They do not care to wait once an initial EOB is received, even if it is obvious something isn't being processed correctly.

Many years ago I had an ultrasound to rule out suspected ovarian cancer. The primary insurance refused to cover it because I had had 2 Cesarean sections proving I had (and I am not joking) pre-existing ovaries. The primary insurance didn't even have to pay, just process, allow the amount, apply it to deductible, and then the secondary would pay in full.

It took me 18 months to get my money back, not to mention hours on the phone and many letters. I refused to back down.

I think sometimes they just prolong things because many people just give up and pay it.

Re: I won my appeal!!!!

ROMARY — Fri, 25 Aug 2017 19:57:44 GMT

Vivian: Fabulous and caring doctor. Please thank him from all of us. What a great role model for the other doctors in his practice.

Re: I won my appeal!!!!

IMW — Fri, 25 Aug 2017 20:00:29 GMT

Inspiring! How did you do it? How many calls, letters emails etc did it take.

Re: I won my appeal!!!!

chrystaltree — Fri, 25 Aug 2017 20:07:59 GMT

@NicksmomESQ wrote:
Some years back I had an emergency procedure in my doctors office.My insurance company denied the claim stating that the procedure required pre approval. Doctors office submitted documentation to show there was no time to get prior approval.They stood by their denial.
My doctor called & insisted on speaking not to a claims person or manager but to the doctor overseeing the people who issued the denial.He got the runaround but was persistent until he spoke to the doctor in charge.
The bill was paid in full & my copay was waived !!
Insurance companies want to avoid bad publicity.If you make a fuss & have a good argument they usually pay up.

There would be no publicity at all over something like that. They overturned the denial and comped the copay, because they were wrong. Remember that claims aren't processed by humans anymore. There are no people in the process, it's all computers making determinations based on procedure and diagnosis codes and just one digit off or one missing code can be the difference between a payment and a denial. You got attention because your doctor called the medical director and had what we in the business call a "peer to peer" conversation. Even if a denial is incorrect, the medical director can overturn a denial and they sometimes do as professional courtesy to another physician. Some doctors get involved with denials, some don't but it certainly never hurts to ask.

Re: I won my appeal!!!!

Drythe — Fri, 25 Aug 2017 20:17:23 GMT

@hoosieroriginal Congratulations to you!

Had some (what I thought was minor mos surgery) 3 years ago. The bill was over $10,000! And it kept going up. A Dr. I'd never seen before, and certainly won't again.

Things just kept being denyed which I knew should be covered. Called and called, and called my inurance until I finally worked far enough up the food chain to get some help.

GULP - it ended up in an insurance fraud investigation against the medical practice. My insurance company told me to forward all bills to them + the called the Dr. and told them NOT to call or mail me anything else as it was under investigation.

They had double billed me for many things, charged me for dressing changes, this was for a tiny growth on my calf, each dressing change was 700.00. Should have been part of the cost of the surgery. Anesthesia services - nope - none of those! Medication - it was iodine swabs.

Finally after 9 months the whole bill was corrected and, I owed $0. Have to hold on like a snapping turtle to get these matters fixed.

Makes me feel bad about the people who don't have the knowledge, time, or wherewithal to sit over and over again on hold during regular working time.

Re: I won my appeal!!!!

hoosieroriginal — Fri, 25 Aug 2017 20:16:07 GMT

@IMWEvery month, I got a bill from hospital, then I'd have to call to see if appeal finalized, if not, another call or letter to the hospital explaining why I wasn't paying.

Re: I won my appeal!!!!

hoosieroriginal — Fri, 25 Aug 2017 20:20:15 GMT

@Drythe wrote:
@hoosieroriginal Congratulations to you!

Had some (what I thought was minor mos surgery) 3 years ago. The bill was over $10,000! And it kept going up. A Dr. I'd never seen before, and certainly won't again.

Things just kept being denyed which I knew should be covered. Called and called, and called my inurance until I finally worked far enough up the food chain to get some help.

GULP - it ended up in an insurance fraud investigation against the medical practice. My insurance company told me to forward all bills to them + the called the Dr. and told them NOT to call or mail me anything else as it was under investigation.

They had double billed me for many things, charged me for dressing changes, this was for a tiny growth on my calf, each dressing change was 700.00. Should have been part of the cost of the surgery. Anesthesia services - nope - none of those! Medication - it was iodine swabs.

Finally after 9 months the whole bill was corrected and, I owed $0. Have to hold on like a snapping turtle to get these matters fixed.

Makes me feel bad about the people who don't have the knowledge, time, or wherewithal to sit over and over again on hold during regular working time.

@Drythe - WOW! Really scary - I think this is more common than we think. Most people don't pay as much attention to their medical bills as they should.

Re: I won my appeal!!!!

elizabethl123 — Fri, 25 Aug 2017 20:38:26 GMT

good for you a company who i ordered a few things from signed me up for discounts well when i got my bank statement saw a statement for 20 bucks so called them she said by you joinging you can save money on future orders i told her NO will not pay that charge now have to wait and see if it was taken off my charge

Re: I won my appeal!!!!

Pqfan — Fri, 25 Aug 2017 20:40:46 GMT

@hoosieroriginalCongratulations on winning your appeal!

Re: I won my appeal!!!!

panda1234 — Fri, 25 Aug 2017 21:02:39 GMT

They really make you work for it.

Re: I won my appeal!!!!

software — Fri, 25 Aug 2017 21:26:54 GMT

@hoosieroriginal wrote:
My medical insurance refused to pay my ambulance bill over a year ago when I had a kidney stone attack. They stated it was a "non-paid benefit". After I looked at my insurance benefits, I saw I had a $200 deductible for ambulance service. I immediately wrote a letter of appeal. It has taken 10 MONTHS for this process because the hospital wasn't getting my insurance company all of the medical records. The hospital kept billing me for the $3,000. I kept telling them I appealed and that it was them who was holding up payment by not getting my insurance company the medical records. Today I received yet another bill from the hospital (the last couple of months I have not received a bill because they finally got the idea it was under appeal). I called my insurance to find out the status of my appeal and she informed me I won my appeal. She told me to tell the hospital it will process the payment in several weeks. So I wrote a letter to the hospital enclosing their last statement (if you call you are on hold 45 minutes) and advising them payment would be forthcoming from my insurance company. Whoo hooooo! Moral to this story - don't stand idlely by and let insurance companies walk all over you! . It takes a lot of effort, a lot of phone calls, but it's worth the fight.

I have similar horror stories myself.

An appeal should take no longer than 90 days.

Congratulations!