Insurance company denied $20k+ claim

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DCA2021
Posts: 16
Joined: Sat May 08, 2021 2:28 pm

Insurance company denied $20k+ claim

Post by DCA2021 »

Hoping for some help or guidance from the community. Long story short my child had an eye issue and we brought him to the pediatrician, pediatrician recommended we go right to ER, ER doctor wanted to admit them/it was late in the day and they couldn’t do an mri until following day, eye doctor at the hospital said we can go home, then ER doctor stormed in and said absolutely not you need to be admitted and get an MRI. We followed this recommendation and were admitted. today we received a letter from our insurance carrier Stating our request for appeal has been completed and claim is denied. We didn’t even file an appeal I think the hospital did but unsure now it’s showing we owe over $20k.

What should we do?
BruDude
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Location: Las Vegas

Re: Insurance company denied $20k+ claim

Post by BruDude »

DCA2021 wrote: Thu Aug 04, 2022 8:46 pm Hoping for some help or guidance from the community. Long story short my child had an eye issue and we brought him to the pediatrician, pediatrician recommended we go right to ER, ER doctor wanted to admit them/it was late in the day and they couldn’t do an mri until following day, eye doctor at the hospital said we can go home, then ER doctor stormed in and said absolutely not you need to be admitted and get an MRI. We followed this recommendation and were admitted. today we received a letter from our insurance carrier Stating our request for appeal has been completed and claim is denied. We didn’t even file an appeal I think the hospital did but unsure now it’s showing we owe over $20k.

What should we do?
What was the reason the claim was denied?
runninginvestor
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Joined: Tue Sep 08, 2020 8:00 pm

Re: Insurance company denied $20k+ claim

Post by runninginvestor »

Hard to tell without knowing the reason denied and the plan details. You may be able to appeal further. Are they denying the stay, the procedure, or both?

For instance, some plans require notification of any inpatient state w/in 24hrs of admittance.

If they are denying the procedure, some plans require the provider to handle all prior authorization requests; doubly so if you are an inpatient. Some plans require the patient to ensure prior auth.

If I had to take a guess, there's likely conflicting or missing documentation from the doctor with the reason why they required the patient to stay. Since you mentioned there was originally orders saying the patient could leave. See if you can escalate the appeal further.
Topic Author
DCA2021
Posts: 16
Joined: Sat May 08, 2021 2:28 pm

Re: Insurance company denied $20k+ claim

Post by DCA2021 »

Basically states they didn’t have a “catastrophic” condition so there wasn’t a reason to stay. No procurer was done. Basically checked us into a room, slept the night, mri in the morning, reviewed by doctors and we went home. TBH, we thought it was overkill but we weren’t comfortable leaving and going against doctor opinions.
simplextableau
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Re: Insurance company denied $20k+ claim

Post by simplextableau »

The provider and patient can both appeal a denial, so it sounds like the provider appealed and was denied. The provider will probably file a further appeal. There is a reasonable chance that the insurer will reverse its decision based on the provider's appeal, but you don't want to rely on that. The most important thing is to be sure you appeal within your own appeal deadline, so track that closely.

I have seen many cases where scumbag insurers refuse to pay, claiming the services were not medically necessary. Usually they cherry pick symptoms and distort the medical records, and then have their own hired guns opine that the treatment wasn't necessary. In one case, the insurer refused to cover an ICU admission for a patient who had serious cardiac symptoms (and test results) and the hospital took her straight to ICU. What was she to do, get checked out and die? That one was reversed on appeal.

For a few thousand dollars, a lawyer can review the medical records and write your appeal to the insurer. Those often have good results, but obviously cost a bit.

You could go back to the physician who made the decision to admit her, and ask for a letter explaining why it was medically necessary. Then use that letter in the appeal.
JBTX
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Re: Insurance company denied $20k+ claim

Post by JBTX »

Is the insurance through an employer policy? I have found on numerous occasions that the best way to get movement is to go through the equivalent of the director of benefits of your employer. They will likely forward you to a company rep for the insurance company, and at that point they are motivated to try to solve the problem if there is any way they can.
mhalley
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Re: Insurance company denied $20k+ claim

Post by mhalley »

Each insurer has their own way of appealing denials. There is an internal appeal, and if that fails, an external review. So get the paperwork from your insurer to file.
Internal
https://www.healthcare.gov/appeal-insur ... l-appeals/

External
https://www.healthcare.gov/appeal-insur ... al-review/
If both these fail, then you might contact your state insurance commissioner.
DarkHelmetII
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Re: Insurance company denied $20k+ claim

Post by DarkHelmetII »

1) get detailed medical records with doctors notes
2) get itemized bill with diagnosis/ icd-10 and procedure/ cpt codes
3) contact DOL ERISA office - before they do anything you must first demonstrate that appeals process has been exhausted
4) make sure you understand the type of appeal - for example some are specifically to adjudicate medical necessity
5) download hospital contracted rates on website and compare to your explanation of benefits
6) aggressively call both the insurer and hospital several times per week noting names, date and time, asking for name of supervisor etc.... to hold them accountable to what was promised as an action from the previous call
7) inquire hospital about any sort of quick pay discount
8) see if your state or city has any sort of health insurance ombudsman
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8foot7
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Re: Insurance company denied $20k+ claim

Post by 8foot7 »

JBTX wrote: Thu Aug 04, 2022 9:22 pm Is the insurance through an employer policy? I have found on numerous occasions that the best way to get movement is to go through the equivalent of the director of benefits of your employer. They will likely forward you to a company rep for the insurance company, and at that point they are motivated to try to solve the problem if there is any way they can.
This is great advice. For something like a $20k denied hospital bill, this is the route to go, while also starting any appeals you can through the formal process (so that you secure your rights and don't lose them due to non-timely filing).
jebmke
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Re: Insurance company denied $20k+ claim

Post by jebmke »

8foot7 wrote: Fri Aug 05, 2022 9:48 am
JBTX wrote: Thu Aug 04, 2022 9:22 pm Is the insurance through an employer policy? I have found on numerous occasions that the best way to get movement is to go through the equivalent of the director of benefits of your employer. They will likely forward you to a company rep for the insurance company, and at that point they are motivated to try to solve the problem if there is any way they can.
This is great advice. For something like a $20k denied hospital bill, this is the route to go, while also starting any appeals you can through the formal process (so that you secure your rights and don't lose them due to non-timely filing).
I've done this before as well.
When you discover that you are riding a dead horse, the best strategy is to dismount.
Jack FFR1846
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Re: Insurance company denied $20k+ claim

Post by Jack FFR1846 »

Find an itemization of the charges.

If the hospital and doctors are all in plan, they have limits on what they can charge. Are you required to call your insurance to be pre-approved? Is so, did you?

I agree to bring it to your employer by doing a 2nd appeal. I've done this based on the stupidity of the system where the hospital was in plan, the overall system that the hospital belonged to was in plan but the ER doctor for some reason was not. 1st appeal denied. Second appeal, I know our HR person was involved, thought it was stupid that they weren't paying the difference in the doctor's charge (like $200) and appeal was granted.
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Big Dog
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Re: Insurance company denied $20k+ claim

Post by Big Dog »

First off, wait for your EOB to see what was paid/not paid. For example, was the overnight room not approved? Or, the MRI? the ER facility fee? The ER doc? Or some/all of the above? (Kinda hard to appeal when you don't know what exactly you are appealing.)

What does your Plan say? PPO/Managed Care? In network/out-of network? Is your Pediatrician the primary care doc with admitting responsibility/authority?
BruDude
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Re: Insurance company denied $20k+ claim

Post by BruDude »

DCA2021 wrote: Thu Aug 04, 2022 9:17 pm Basically states they didn’t have a “catastrophic” condition so there wasn’t a reason to stay. No procurer was done. Basically checked us into a room, slept the night, mri in the morning, reviewed by doctors and we went home. TBH, we thought it was overkill but we weren’t comfortable leaving and going against doctor opinions.
Was this an out-of-network claim?
JeanneForever
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Re: Insurance company denied $20k+ claim

Post by JeanneForever »

Agree with Big Dog to see what the hospital is charging for what service(s).

We got a similar letter from an ER visit that had radiology, procedures, an overnight stay. The hospital wanted to bill for an inpatient admission, but the insurance considered it an observation stay. Admission vs. observation could be what the denial is for.

We ended up only having to pay the ER copay, which would have been waived for a true admission. Not sure if it matters in terms of how insurance treats it, but ours was an indisputable emergency prospectively and retrospectively. However, that doesn't mean the overnight stay was a true "inpatient admission," for which the hospital gets more $. Note also that the ER doctors did use the word "admit," as they did for another observation stay for something else that turned out to be less severe, but we didn't have any insurance issues with that one.
JHU ALmuni
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Re: Insurance company denied $20k+ claim

Post by JHU ALmuni »

OP - Don't go back and forth with the insurance company. Just call the hospital and ask them to submit the documentation why your son got admitted. Happened to me before.
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