Quantcast

AVM Survivors Network

Insurance Appeals

Anyone have any experience in insurance appeals. Just got a bill today for $320 for two doctors that saw Dev for all of 5 mins each, that I didn’t have a say in. Needless to say I wouldn’t have allowed those docs had I known that my insurance would deny their fees.

I would start by getting a letter from the doc who referred you to see them. The letter should state why it was critical to Dev’s care that he see those two docs. Then you write as long a letter as possible about why they should cover these doctors and why Dev had to see them in your own words as well.

That’s the hard part. These were regular peds docs with permissions at the hospital. Not specialists. One was a check on Dev while he was in the PICU after he had been taken off ICU status, the other had to see him to order some labs when he got a touch of flu in the inpatient rehab. They were pretty much assigned to see him and just showed up, took a look at him and left.

I would also contact the ped docs (the finacial dept) that saw your son and see if they can help influence the insurance company. I am sure they can come up with a negotiated price. We had a lot of insurance hoops to jump through. Our neurosurgean was out of our network as he was in another state. The drs office has a lot of experience with this sort of thing and between my husband and I writing long letters and the doctors office negotiating and also re-iterating that this was not carpal tunnel surgery but something so complicated that they better think twice about patient outcomes. The insurance company was trying to find a dr in our network. It was a crazy time! The neurosurgeon in our network actually told us our son was inoperable (weeks prior to the beginning of our fight with insurance). Keep pushing for the insurance to cover it and/or the ped drs to forgive the $320. We really had to push hard. It is ashame that you have to worry about this sort of thing when you have so much bigger things to think about. Wishing you and of course Dev well.

Well to update. Our insurance company told me that the billing people used an outdated code and needed to rebill because they haven't yet.

So I call the billing people and explain what insurance told me, and she said that they rebilled and was going to pull up the EOB and call me back to explain why the charge denied. So she called back and said that they don't contract with our plan (which doesn't matter because they paid part of one claim for one the doctors) and I need to call insurance because she couldn't and ask for an explanation. I told her again that I already called insurance and they told me that the claim was denied due to coding and that they haven't got a rebill with the right code. Then she was surprised and didn't know what code it should have been and then suddenly she can call the insurance company.

So she calls them and then calls me back and says the insurance company told her the right codes and then she has to get approval from her manager to rebill and then call me back when she gets approval to rebill.

sigh…and so it goes…navigating the nutty insurance and billing rules. It is really stressful and eliminating this would be great but sometimes it kept me from focusing of the whole situation. Still though…I would rather not have to have bothersome phone calls and messages like the one you just had. At least it sounds like they will cover it. Keep pushing!

StarieNite said:

Well to update. Our insurance company told me that the billing people used an outdated code and needed to rebill because they haven't yet.

So I call the billing people and explain what insurance told me, and she said that they rebilled and was going to pull up the EOB and call me back to explain why the charge denied. So she called back and said that they don't contract with our plan (which doesn't matter because they paid part of one claim for one the doctors) and I need to call insurance because she couldn't and ask for an explanation. I told her again that I already called insurance and they told me that the claim was denied due to coding and that they haven't got a rebill with the right code. Then she was surprised and didn't know what code it should have been and then suddenly she can call the insurance company.

So she calls them and then calls me back and says the insurance company told her the right codes and then she has to get approval from her manager to rebill and then call me back when she gets approval to rebill.

Where I worked, the company was large enough (about 20,000), the insurance carrier had at first a few, and then it dropped to one, representative on site. This gal was a jewel! She understood the insurance side of the company, so all you had to do was take your statements or questions to Debby, explain it to her, and she would work it or tell you what you needed to do.

She saved me countless hours trying to deal with it ourselves.

Is it possible that your provider has a customer rep that can step in to help work these things, instead of you doing it?

Hope this helps.

Ron, KS