How does one appeal a health insurance denial?
April 3, 2013 10:55 PM   Subscribe

A specific health care claim was denied by my insurance as not medically necessary. What are my options?

Last fall, I experienced a sharp pain in my esophagus area that was particularly painful every time I swallowed, particularly when swallowing food or drink, and more particularly when swallowing solid food. The pain started just around the time -- very likely immediately after -- I drank a glass of wine that could have had a small shard of glass in it.

A nurse and doctor recommended I see an ear, nose, and throat doctor. That doctor recommended that he do an endoscopy - it's possible there was a cut in my esophagus from the glass. (Another possibility he said was that I had an ulcer in my esophagus caused by taking too many ibuprofen to try to keep this pain down. I thought that seemed to mix up cause and effect, but eh.) He and the anesthesiologist, to my recollection, said that I should be knocked out while they did the endoscopy, so I was.

In the end, they found something that was not all that serious, the doctor prescribed me something to coat the inside of my esophagus, and after a few weeks the pain went away. Yay!

Months later, I find myself with a bill from the anesthesiologist for a fairly significant amount (about equal to one paycheck, and I live paycheck to paycheck). The health insurance denied the claim for anesthesia because it was not medically necessary. All other claims (from the hospital, the ENT doctor, etc.) it approved many months ago.

I will spare you my rantings about the American health care system, the fact that a for profit company seems to overruling a medical doctor regarding what is medically necessary, etc., etc...

My question is, what can I do to fight this? Can I appeal to the health insurance company, and if so, how?

(I'm guessing my one of my options would be to try to get financial assistance, a payment plan, etc. But that'd be from the anesthesiologist -- that's separate. First, I'd like to try to get the health insurance company to pay what I see as its fair share!)

Is it possible to go to the doctor and get him to vouch for the fact that the anesthesia was medically necessary? Is this something that doctors do? If it is something that doctors do, is it something that works? Have you been in a similar situation? How did it end up? I'm interested most of all in practical strategies that are most likely to get the health insurance company to change its ruling.

TLDR: surprised by a health insurance ruling that anesthesia was not medically necessary, looking for advice on how to get them to change their minds.
posted by lewedswiver to Health & Fitness (7 answers total) 1 user marked this as a favorite
Absolutely. Ask your doctor to write you a letter.
posted by fshgrl at 11:02 PM on April 3, 2013 [1 favorite]

My understanding is that there's going to be an internal appeals process specified in all of the contracts and boilerplate paperwork you should be receiving from them regularly. I unsuccessfully disputed a decision with my local BCBS when I had my insurance through them; but it was a much less firmly-founded case than you've got and with less motivation - I basically just didn't like one of their rules and was annoyed enough to ask for an exception.

I think you should read up on the particulars of your appeals process (which may have several levels), get the doctor to write the letter fshgrl suggests, gather up your other evidence as if you'll be appearing on Judge Judy, and kick off the appeals process and make your case.

If an internal appeal doesn't get you what you need, there are several other routes you can pursue. There should be a state insurance board or state consumer protection bureau who can help you with this - in my tiny New England state I've been really impressed by how quickly they call me back and how energetic and professional they are. (They usually wanted copies of all correspondence between me and the insurance company, so keep that in mind as things progress with any internal appeal; if someone tries to prod you into resolving issues over the phone you should probably decline and insist on written communication, or at the very least take good notes on a phone call and badger them into confirming what they said in writing afterwards.)

Then I believe beyond that you've always got legal options, but I don't know any of the details on that.
posted by XMLicious at 1:44 AM on April 4, 2013 [3 favorites]

Most likely the appeals process is going to be an arbitration process with a board they have set up internally for that exact purpose. It should be all spelled out in your certificate of coverage.
posted by COD at 4:27 AM on April 4, 2013

You should contact that doctor's office's billing people immediately, asking them to write a letter of medical necessity or certificate of medical necessity.

I worked for a GI practice, and I'm very surprised that the ENT would not have included something like this in the paperwork to the insurance company as part of their billing for the endoscopy. Most people need to be given at least "conscious sedation" when they have an endoscopy.
posted by kuanes at 6:36 AM on April 4, 2013 [3 favorites]

Be persistent. It's a lot of money to you, but not so much to the insurance company. As noted, enlist the doctor's assistance in getting the claim paid. Every state has an insurance commission, and a consumer affairs department, and they may be able to help you if you keep hitting a brick wall. You can find the contact info on the state's web page, usually as part of the attorney general's office.
posted by theora55 at 7:20 AM on April 4, 2013 [1 favorite]

Seconding kuanes a million times over!

I have found it easier to get things done through the billing office of the provider than by doing it myself.

I routinely deal with our insurance company for a variety of reasons (one part is really excellent, the other part --- a contracted group for a different set of benefits --- is terrible), and calling up the provider and saying, "This is going on!!!" has been the absolute best way to get it handled.
posted by zizzle at 9:30 AM on April 4, 2013

If you have a human resources department, try contacting them. They might have someone who acts as a liaison between employees and the insurance company.

About a year ago, my insurance company was denying that my primary care physician ordered a specialty consult when in fact he had. I explained that I had his on-line instruction to make the appointment via their patient interface, and they said that I needed to print it out and mail it to them. Instead, I called HR, followed up with a PDF of the documentation and got approval that same day.

Maybe your HR people will similarly expedite.
posted by Short Attention Sp at 9:36 AM on April 4, 2013

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