I won my appeal!!!! - Page 3

Carmie · ‎10-25-2010

Congratulations @hoosieroriginal. I am sure you will sleep better tonight with that burden lifted.

When I retired, I wa working on the appeal department for a health insurance company. I had that position for many, many years.

I always advise people on these forums to appeal in writing. You can not do an appeal over the phone.

i am so sorry that it took 10 months for your claim to be approved. Back in the " old days" the appeal rep could just call the hospital or doctor's office and get the information needed and reopen the claim. Now, with the government involvement and HIPAA guidelines, all information must be sent by the provider in writing or changed on the computer.

Your insurance company did not " walk all over you". ..the hospital did. Good for you for not paying the bill. By not paying, they had to submit the records. By not sending in your records, they cost your insurance company a lot of money. Working appeals are not cheap. All of the man hours and record keeping and government guidelines that must be followed cost thousands of dollars sometimes, even before the appeal is denied or approved.

i agree with you that writing an appeal is worth it if you have coverage for a medically necessary service.

I will never forget the time my insurance company denied an emergency room visit as not medically necessary. The patient's daughter called me and she was irate and upset. The procedure code and diagnosis on the claim did not indicated an emergency service. The hospital coded the claim incorrectly.

Imagine how she and I felt when I told her it was not necessary for him to go to the ER according to the information submitted and she said he had a heart attack and didn't survive. the service was 100% covered and definitely medically necessary, but that lady had to appeal that claim before we could review it.

Insurance I said not so simple anymore and it's gonna get worse before it gets better.

hoosieroriginal · ‎03-04-2012

@Carmie wrote:
Congratulations @hoosieroriginal. I am sure you will sleep better tonight with that burden lifted.

When I retired, I wa working on the appeal department for a health insurance company. I had that position for many, many years.

I always advise people on these forums to appeal in writing. You can not do an appeal over the phone.

i am so sorry that it took 10 months for your claim to be approved. Back in the " old days" the appeal rep could just call the hospital or doctor's office and get the information needed and reopen the claim. Now, with the government involvement and HIPAA guidelines, all information must be sent by the provider in writing or changed on the computer.

Your insurance company did not " walk all over you". ..the hospital did. Good for you for not paying the bill. By not paying, they had to submit the records. By not sending in your records, they cost your insurance company a lot of money. Working appeals are not cheap. All of the man hours and record keeping and government guidelines that must be followed cost thousands of dollars sometimes, even before the appeal is denied or approved.

i agree with you that writing an appeal is worth it if you have coverage for a medically necessary service.

I will never forget the time my insurance company denied an emergency room visit as not medically necessary. The patient's daughter called me and she was irate and upset. The procedure code and diagnosis on the claim did not indicated an emergency service. The hospital coded the claim incorrectly.

Imagine how she and I felt when I told her it was not necessary for him to go to the ER according to the information submitted and she said he had a heart attack and didn't survive. the service was 100% covered and definitely medically necessary, but that lady had to appeal that claim before we could review it.

Insurance I said not so simple anymore and it's gonna get worse before it gets better.

@Carmie - I think all of this came as a result of wrong coding also. The "non paid benefit" was improper. One person probably cost the insurance company a lot of money.

hoosieroriginal · ‎03-04-2012

@Carmie wrote:
Congratulations @hoosieroriginal. I am sure you will sleep better tonight with that burden lifted.

When I retired, I wa working on the appeal department for a health insurance company. I had that position for many, many years.

I always advise people on these forums to appeal in writing. You can not do an appeal over the phone.

i am so sorry that it took 10 months for your claim to be approved. Back in the " old days" the appeal rep could just call the hospital or doctor's office and get the information needed and reopen the claim. Now, with the government involvement and HIPAA guidelines, all information must be sent by the provider in writing or changed on the computer.

Your insurance company did not " walk all over you". ..the hospital did. Good for you for not paying the bill. By not paying, they had to submit the records. By not sending in your records, they cost your insurance company a lot of money. Working appeals are not cheap. All of the man hours and record keeping and government guidelines that must be followed cost thousands of dollars sometimes, even before the appeal is denied or approved.

i agree with you that writing an appeal is worth it if you have coverage for a medically necessary service.

I will never forget the time my insurance company denied an emergency room visit as not medically necessary. The patient's daughter called me and she was irate and upset. The procedure code and diagnosis on the claim did not indicated an emergency service. The hospital coded the claim incorrectly.

Imagine how she and I felt when I told her it was not necessary for him to go to the ER according to the information submitted and she said he had a heart attack and didn't survive. the service was 100% covered and definitely medically necessary, but that lady had to appeal that claim before we could review it.

Insurance I said not so simple anymore and it's gonna get worse before it gets better.

@Carmie - oh by the way, yes, put everything in writing. Don't ever do anything over the phone. When it first happened they told me it wasn't necessary to file an appeal - I filed anyway so my appeal period didn't run out - glad I did since it took so long. I always cover my bases - everything always sent certified too so they can't say they didn't get it.

Noel7 · ‎03-09-2010

Good for you!

Congratulations 👍🏻

CAcableGirl2 · ‎06-03-2010

@hoosieroriginalSo happy for you! What a nightmare to go through, imagine the people that have to go through all that and be dealing with life-threating illnesses at the same time.

Just a thought since it took so many months to get this cleared up, you might want to run your credit and see if they have placed any negative marks on your credit report. Better to check now then discover next time you are looking at getting a loan or refinancing.

......You look like I need a drink.....

Lindsays Grandma · ‎03-10-2010

Good for you hoosieroriginal. If everyone took the time and had the patience to do what you did these companies just might get the message...DON'T MESS WITH ME.

The moving finger writes; And having writ, Moves on: nor all your Piety nor Wit Shall lure it back to cancel half a Line Nor all your Tears Wash out a Word of it. Omar Khayam

GCR18 · ‎07-03-2013

My drs all come from the same hospital. The hospital has a patient representative that helps the patient navigate billing issues. I had a radiation bill declined from my insurance company because they considered the type of radiation I received to be experimental. I got no where trying to explain it. I connected with the patient navigator and she was able to cut through the b.s. and had it resolved in a week and my insurance company paid it.

haddon9 · ‎03-09-2010

That's great news! I'm happy for you!

I think it's disgusting how insurance companies try to deny so many for what they are supposed to be covered for.

My 90 year old mother was in a freak accident three years ago. (a man walking through a public space tripped and fell on her bringing her down and breaking her neck & leg).

After being in the hospital for several days she was sent to a rehab hospital. She got there by ambulance. Insurance denied the ambulance because"it wasn't necessary". How did they expect her to get there?...take a taxi or Uber?!! She lives in Fl. and I'm in PA. Even if I were closer I would have been too afraid to take her from one hospital to the other!

She too persisted and finally won after almost a year. It makes me sick to think that when someone is sick or injured they have to fight not only for their health but the insurance companies too! In her case it was Medicare & her supplemental.

Financialgrl · ‎03-13-2010

Not as bad as an out and out refusal to pay but just as frustrating are medical personnel not understanding insurance and billing. I was dad's power of attorney the last two years of his life. He was in ICU twice and on dialysis last 5 months of his life. Dad had Medicare Part A but not B. Instead, he had Anthem BC/BS from his job that carried forward once he retired which was to be used as his Part B.

After each dialysis or hospital stay I'd visit the billing office to remind them they had his Medicare A for inpatient admittances for the bed but all tests, labs and procedures needed to be billed to his Anthem BC/BC. They'd put a note in his file that apparently NO ONE ever read because each month I'd get a bill. I'd send letters and personally visit the office and explain yet again they needed to bill insurance. After 5 months and still receiving bills, now with penalties and interest added, I sent yet one more letter to the hospital and this time with a copy to hospital administration where the last paragraph now was specificaly addressed to them that I had no intention of paying the balance owed because we didn't owe it and if they wanted to get reimbursed, they needed to get their billing office to do their job and bill the correct insurance for reimbursement. This took 7 months to straighten out - persistence pays off but I finally got a "paid in full" invoice. I hate all things dealing with medical insurance and all the bureaucracy they put you through so they don't have to pay!!