Health Insurance Denial for ER/Hospital Stay

December 31, 2022 7:42 PM

Two weeks ago my partner was bitten by their pet. Within 20 minutes their hand had swelled, face was swollen and hives all over. We went to ER, and they were admitted to the hospital for a course of IV antibiotics. Today we got the "not medically necessary" denial.

Partner was on continuous IV for 2 days, and twice daily for the next 3 days. The infectious disease Doctor said the CDC specified course of treatment was 5 days of IV antibiotics, danger of heart damage if not dealt with. On the 3rd day there was a possibility of being discharged with home infusion, but ironically insurance refused to pay for it so there was no other option given but to stay.

Insurance is Anthem® Blue Cross, home, work and hospital is in California Bay area.
We are looking at previous questions about fighting insurance, wondering if there are any new laws that could be helpful.
Also looking to hire a consultant to help us deal with this, so any recommendations or tips?

posted by Sophont to Law & Government (14 answers total)

Have you already contacted the doctor’s billing department? That would be my first step—seeing what they can do to help you appeal this. It’s to their benefit to assist you because it maximizes their chances of getting paid sooner rather than later. Then, depending on what they said, my next step would probably be to call the insurance company and ask what information they can give you about why your claim was denied and how to proceed with an appeal. Definitely don’t hire anyone until you’ve gone through these steps, and depending on your company, also see if your HR department can put you in touch with the Aetna customer service representative for your company (bigger companies are more likely to have one). In my experience, these kinds of insurance shenanigans are pretty common and often require tedious calls and back and forth but ultimately get resolved.
posted by theotherdurassister at 8:20 PM on December 31, 2022 [6 favorites]

Response by poster: We just got the letters today, so no one will be contacted until Monday. My thinking is to hire someone first before contacting the insurance company. We don't know what we don't know, so I don't want to screw something up that a consultant could have warned us about. Letter said there are details about the denial accessible through the website.
posted by Sophont at 8:36 PM on December 31, 2022

I would recommend trying to contact them yourself first before paying someone you don't know out of pocket to do something on your behalf. You still have options, and it's worth trying to figure out what those are rather than immediately looking for someone to solve the problem. If you can avoid paying expensive fees, that would surely be more desirable.
posted by Alensin at 9:11 PM on December 31, 2022 [9 favorites]

I think you’re getting a little ahead of yourself. There’s no good reason to hire someone for this yet, and you won’t lose anything by calling your insurance company to ask questions. It’s possible this will be complicated enough, or Aetna will be evil enough, that it’ll be a protracted fight, but it’s entirely possible you’ll be able to resolve this by having the hospital re-bill or provide additional documentation. Moreover, if your HR department isn’t terrible, and you can’t get this resolved with the hospital’s help, they’ll be worth consulting. They should care if the insurance they’re offering isn’t providing the benefits they’re paying for. Truly, you have several steps to take on Monday, and no reason to stress until then or assume you’ll need to hire someone to help get through this.
posted by theotherdurassister at 9:54 PM on December 31, 2022 [9 favorites]

California Department of Insurance

"We can answer questions about your policy and assist with issues you are having with auto, home, health, commercial, or other types of insurance."
posted by amtho at 10:26 PM on December 31, 2022 [1 favorite]

Keep in mind that Monday is a holiday (because January 1 is a Sunday), so you probably won’t be able to reach anyone until Tuesday.

My approach when contacting the insurance company would be to treat it as a simple mistake they has been made that need to correct. No need to go in hot, yet.
posted by jimw at 10:44 PM on December 31, 2022 [18 favorites]

Agree that you don't need to hire someone yet, would go through a round of calls with the insurer and the hospital's billing department first.

I don't work in healthcare, have no inside information, but having been through several similar disputes, I believe the standard procedure goes like this:

- insurance automatically rejects any amount over $X with some flimsy made-up reason
- when questioned, insurer says that biller didn't give adequate justification and needs to re-bill
- biller submits extra info
- insurer rejects again with some other lie, e.g. biller didn't use the right code for the treatment, etc.
- repeat until the insurer gives up and pays (which with their negotiated discount, will probably be something like 10% of the cost that you're currently on the hook for!)

Also agree that when contacting insurance/hospital billing, just treat it like a simple mistake to be corrected. Everyone you'll be talking to knows exactly how the game is played, they know the whole process is bullshit.

It'll be a lot of stress and annoying work over several weeks, having to nag both sides repeatedly to keep things moving along. But they'll probably pay eventually. I personally wouldn't be looking to hire outside help unless things seem truly stuck after a couple rounds.

Talking to your HR is a good idea too. If they can magically get you in touch with someone in the higher levels of the insurer's customer service, not the front-line phone people, that could help quite a lot.
posted by equalpants at 11:04 PM on December 31, 2022 [11 favorites]

Until you get a bill from the actual hospital or physicians etc. who provided you services, this is a negotiation between the hospital (or physician group, etc.) and the insurance company. My son spent his first week of life in the NICU and we got several rounds of EOBs for months that showed denied charges and different responsibilities for us for various reasons; none of it mattered until we got a bill from the hospital.
posted by MadamM at 11:22 PM on December 31, 2022 [3 favorites]

You definitely don’t need to hire anyone yet. Insurance companies win these fights mainly on attrition. Nthing getting the hospital’s billing department involved and calling and bothering your insurance yourself.
posted by shadygrove at 11:35 PM on December 31, 2022

Best answer: Never Pay the First Bill
posted by flamk at 11:39 PM on December 31, 2022 [10 favorites]

Slow down on the hiring a consultant idea. It's probably going to be 4-6 months before the hospital and insurance company get their acts together and agree on a final cost, so just relax, keep all your documentation, and keep good notes from every conversation. The hospital will almost certainly resubmit the bill "for review" internally, and that is likely to take 4-12 weeks before you hear anything.
posted by COD at 6:57 AM on January 1, 2023

It’s also completely fair to call the insurance company on Monday, we have an entire public school system that’s open tomorrow. It’s worth a call.
posted by childofTethys at 6:59 AM on January 1, 2023

Seconding the idea that you handle this through your work. Your workplace benefits coordinator will be able to contact someone much better placed than the front-line customer service agent.

I had a very medically necessary surgery denied, and after the initial panic I emailed HR, and everything was taken care of.
posted by hwyengr at 9:30 AM on January 1, 2023 [2 favorites]

I have a weird prescription that makes my insurance cranky. It gets denied every time. The doctor's office handles it without me even having to contact them. They get the denial notice too and usually get it fixed within a day.
posted by nixxon at 3:40 PM on January 1, 2023