What to do when your insurance denies a claim?

In My Humble Opinion
1

Long story short: Husband is out of state on a work related business trip. He becomes violently ill and thinks he’s having a heart attack. (Back story: He’s young (45) and in really good shape, but his father, grandfather and 3 of his 4 uncles didn’t live to see 50 because of heart issues.) He is rushed to the hospital, where he spends 36 hours as an interim (not in-patient but not quite out-patient) patient. After a battery of tests, it’s determined that he suffered a panic attack brought on by stress. (He’s a stock broker.)

Insurance was notified by me a few hours after he’s admitted to the ER. They advise me to just “let the doctors do their job.”

Now the bills are coming in, and while the insurance has paid the bulk of the bills, they are denying a few of the individual bills, saying that they were out of network and not authorized. Now they are billing us directly for the services. Our insurance card says right on it that for emergencies, go to the nearest emergency room. That’s what he did. We assume that everything they do in the hospital is medically necessary and directly related to this emergency.

So far the “denied” bills are for $260, 345, and 420.

Note: If it’s worth anything, they presented him a paper that said he’d be responsible for payment, but he never signed it, and they never asked for it. In fact, we took the paper home with us.

So. Would you pay them? Ignore them? Appeal them? Ask husband’s company to pay them because he was out-of-town due to his job? Try to negotiate to lower the bills?

On the one hand, I don’t want to stiff anyone. They took good care of him. On the other, we pay damn good money ($850/mo.) to get decent insurance coverage. And it’s not like he planned to have a panic attack out-of-network. And I’ve seen how the insurance companies reduced all the submitted bill by 1/3 or more – why should “uninsured” people pay an inflated, unadjusted rate?

2

Call your insurance company, point out the bills are for an ER doctor which is supposed to be covered.

I had the same thing happen to me (just one bill). Called, pointed it out, it was re-submitted and paid with no further hassles.

It’s possible someone didn’t notice it was an ER charge.

3

Insurance companies make mistakes like that all the time. ER emergencies are almost always covered in full after the initial copay. Don’t pay them yourself at all. Just keep calling the insurance company until they pay them. You will eventually get someone willing to take care of it. It is probably due to an oversight in the nightmare that is the medical billing process and not a real attempt from them to get out of paying.

4

I would do this:

First: Pay the bills directly to the hospital. Alternately, contact the billing department of the hospital and advise them that you are appealing the coverage decision with your insurance, and make arrangements for a payment plan. The hospital will likely work with you on this. Either way, it keeps the hospital from reporting you to a collection agency for non-payment of debt. And, whether you signed the form or not, you do owe the hospital for treatment if your insurance won’t pay.

Next: Appeal the non-coverage decision with the insurance agency. Likely the bills are for specific doctors or departments, and were submitted separately from the general emergency bill, even though they are at the same facility. Insurance companies process claims each on its own, not in a “big picture” sort of way. It’s likely they didn’t associate the individual bills with the emergency treatment even though they may have the same service date. If you call the insurance company and explain the situation, they will reprocess, your claim with the “new” information.

  1. Keep appealing with insurance until you get paid. Remember that insurance companies will go to great lengths to not cover claims, as this benefits their shareholders. They don’t care about you or your husband. This will take a long time and be very frustrating. Don’t give up.

  2. Once you have gotten insurance coverage (and received Benefit Explanations) for a service, wait a month for the doctor to get the check. Then call the doctor’s office and request a refund for overpayment. Alternately, if you can, get the insurance company to send you a check directly. This is more difficult and probably involves more paperwork.

Advice for dealing with insurance company representatives:

– Document every conversation you have, including date, time, who you spoke to, the question you asked, and what you were told. If following up, recite the call history to the person you are talking to - this demonstrates you’ve been keeping track and are not going to be blown off.

– Always be polite, but firm - rude or aggressive will not get you what you want.

– If anyone tells you “you can’t appeal” or “this decision is final” ask to speak to their supervisor. Keep working up the chain until you get what you want.

– Ask how long a process will take. If they tell you 30 days, call back on day 31 to get a progress update. Don’t wait for them to contact you - they WILL put off action as long as they think they can get away with it.

– Be honest. If at any time you lie, they can deny coverage.

IANAL or work for an insurance company. I just have many long years getting coverage for my husband’s chronic condition. Remember that internet advice is worth what you pay for it :slight_smile:

ETA: Shagnasty, I don’t agree with not paying yourself. At very least, contact the provider and let them know you are appealing the decision. Reprocessing requests from insurance companies can take 60+ days. In that time, the hospital can decide you aren’t going to pay and send you to collections, which does permanent damage to your credit rating.

5

It usually takes a lot longer than 60 days to get sent to a collection agency. It also depends if you need credit in the near future or not. It is unlikely that the insurance company will not pay after a call or two but it is harder to get them to reimburse you than to pay the hospital in the first place in my experience.

6

Agreed. Do not pay the bill yourself except as a last resort.

7

I had to fight an insurance denied claim. It took about six months, but they paid them. It IS NOT a pleasant experience, but they want you to back down.

The thing is you need to find people that can help you. I started out with the low level clerks. Well they can’t help you and you’re wasting your time. Start with them, be NICE, you only get places by being nice. If people like you they want to help you.

Then say “Look, I know you’re just an employee, you can’t help, but can you tell me the name of your supervisor or someone who might be able to?” The clerk will be only too glad to pass the buck.

That’s the key, finding the right people who CAN assist you.

Good luck

8

Thanks for the advice. I guess I’ll be making some phone calls tomorrow.

9

Does your husband’s company have a rep that deals with insurance?

My parents always go to dad’s union insurance rep first, with any insurance problems. Now, this is a UNION insurance rep through his UNION, so I am not sure if having a rep like this is standard for most big companies. But, at least in dad’s case, there is someone available to help.

10

It took me over 2 years to get the insurance company to pay my father’s medical bills, but I did finally win.

You will probably have to call, call, call a million times until the insurance company gives you justice (assuming their denials are illegitimate). Some tips:

  1. Document every call to the insurance company. As soon as you call, ask for the identifying information of the person you are speaking to. They won’t give you a full name, but they’ll say “Fred from Dallas, ID number 74522” or “this call is event number 34787-4815 and if you want to refer back to it when you call again, use that number.” That’s fine, just be sure you get it, and get it AT THE BEGINNING of each call.

  2. Take copious notes of everything that you are told each and every time you call. Make sure you note the time and date of each call.

  3. While there is no need to be uncivil to some poor person just trying to earn a living at a miserable job, do not hesitate to be pretty aggressive and raise your voice if have to when you are being given contradictory or unsatisfactory information.

  4. If after months of this you are not getting anywhere and you believe you really have a case against them, contact your state insurance commission and file a complaint.

In my experience - and it is pretty substantial at this point - the insurance company just wants to wear you down until you throw your hands up in dismay and calculate that the stress of arguing with them is greater than paying the bills yourself.

11

[nitpick]

Collections only stay on your credit report for seven years. Seems like forever, but it’s not.

[/nitpick]

12

Is a “panic attack” a covered incident?

13

Policies obviously vary, but I know that some will not cover ED visits if it was determined that there was no ‘real’ emergency.

I’ve got to believe that a panic attack is not generally considered an emergency.
mmm

14

Having worked for a major health insurance company, I can only say that ours paid emergency care based on “signs and symptoms” upon presentation at the ER; not final (or discharge) diagnosis.

It is assumed the patient is not a physician and therefore not in a position to diagnose him/her self. If presenting indications are, for example, those of a heart attack (chest pains, tightness, trouble breathing, etc.) then the intake or preliminary diagnosis is the basis of payment. The discharge (or final) diagnosis is not used. Discharge diagnosis is recorded, but not a determinant of payment or denial. It doesn’t matter if the final diagnosis was a gastrointestinal problem, panic attack or whatever else.

One of our recurring challenges was training hospital billing clerks to submit claims to us that listed “signs and symptoms” or preliminary/presenting diagnosis as the reason for the emergency room visit, rather than final or discharge diagnosis.

Check with your insurer to see of that’s their payment policy as well. I understood that this was the standard in the industry, but I may be wrong.

15

Of course it is. His symptoms mimicked a heart attack.

Interestingly enough, his younger brother (age 38) had a panic attack the week of Christmas. His symptoms were identical to my husband’s – racing heart, profusive sweating, tightness in his chest, blurred vision, and the feeling that he was going to pass out. When he got to the emergency room, his heart was beating at 145 bpm and they couldn’t get it to slow down. They finally had to use paddles to “re-set” his heart. Even though it’s triggered by stress, the uncontrollable adrenaline release is very real and frightening.

The real downside to panic attacks is that patients may decide to self-diagnose and not seek help during the next event, and one day it may be a real heart attack.

16

While the rest of your advice is good, I would think twice before doing this. Don’t ever give anyone at the insurance company reason to dismiss you.

The keywords to keep in mind (IMO) are “polite, clear, and relentless”. The way to get the insurance company to pay is to make it clear that the bother of you constantly hassling them, over and over and over, is greater than the bother of paying the claim and getting you out of their hair.

The response to "I am sorry I can’t help you’ is “please put me thru to your superior, or whoever can help me” and don’t get off the line unless they transfer you. If someone says “that’s Billing’s responsibility” the answer is “please put me thru to Billing”.

I had this sort of situation in the past. After going up from Customer Service two levels, I wound up finding out the name of the president of the organization and copying him on my letters. Everything I wrote to him mentioned the names of the people who claimed they were working on it, the timelines when they claimed to be working on it, and a clear statement of what I wanted to happen - “the outstanding balance is $XXX.XX. Please pay that amount, and send me written notice that this is done.”

Be polite, but make it clear that nothing whatever will work to make you go away except if they pay the amount.

Regards,
Shodan

17

Update: Husband called about the unpaid claims. An insurance rep said that they had been miscoded (they needed to be coded as an emergency) and will be re-processed and paid within 15 days.

Thanks for your advice. Crossing my finger that this will be the end of it.

18

My wife had a few emergency visits this year, and we got a stream of “bills” and copies of discussions between the insurance company and the hospital. I called the insurance company and they told me not to worry that we weren’t responsible for it.
That’s just they way that they all operate.

19

A co-worker several years ago had a panic attack and presented to the ER with very similar symptoms. His bills were completely denied by the insurance company because it wasn’t a “life-threatening emergency”. He eventually got it resolved but not without a lot of complaining up through our chain of command.

20

I dunno. I went to the hospital for an emergency appendectomy three years ago. The insurance company refused to pay as it was an out-of-network hospital. I appealed it and they refused again.

I am still paying on that bill.