Advice on appealing "ineligible amount" decision by health insurance?
September 29, 2017 9:30 AM   Subscribe

My Calif. health insurance company just returned a claim saying that they will pay $30 less per visit than they used to based on the "reasonable and customary" charge they think the service should cost. But they used to reimburse at a higher rate, and it doesn't make sense that the "reasonable and customary" rate would decrease. Does anyone have advice on appealing?

I read this old AskMe question about the "reasonable, usual and customary charge" so I'm familiar with the concept.

But, my insurance company *was* reimbursing the actual $ amount charged, within the same claim year, from the same doctor and the same diagnosis.

It doesn't make sense that the "reasonable" amount for a doctors' visit would go down over time - that goes against inflation, cost of living increases, etc. for doctors. I live in the SF Bay Area and the health insurance company is in CA.

This insurance company has very frequently "lost" the claim forms I mailed in, mails the payments to the wrong person, and other completely incompetent behavior, so when I get through (their phones are mysteriously down this morning! Huh!) to them my first step will be to ask them to review the claim again.

But if they stick to the "reasonable and customary" categorization for this medical service, how best could I appeal it/complain since they HAD been reimbursing the whole amount before, in the same claim year, same provider, same service, and never notified me of any change in their policies.
posted by rogerrogerwhatsyourrvectorvicto to Health & Fitness (6 answers total) 2 users marked this as a favorite
Each of the EOB's I receive includes about 6 pages of fine print on how to appeal the claim. Presumably your insuror also has an appeal procedure? My advice on how to appeal would be to follow your insuror's appeal procedure.

Regarding the "how best could I appeal it/complain" part of your question, appealing is more likely to get results than complaining. Again, look at the EOB's and other literature the insuror has sent you already.
posted by JimN2TAW at 12:15 PM on September 29 [1 favorite]

I love AskMe, but some questions bump up against our relatively limited number of members. I'd recommend you ask /r/Insurance/; there are 13,431 people who subscribe to /r/Insurance (indicating a certain interest and knowledge level in insurance matters) and more than that who occasionally stop by.
posted by vegartanipla at 12:23 PM on September 29 [4 favorites]

Your intuition on costs is incorrect. Payers -- basically, Medicare, Medicaid, and the insurance companies -- are constantly cutting back reimbursement rates for established modalities of therapy. Modalities of therapy are supposed to become cheaper over time as providers become more efficient and training and capital costs are amortized, and cutting reimbursements forces providers to achieve those efficiencies. Wal-Mart and Target do this too -- unless your product is new and improved, your wholesale price is required to go down every year.
posted by MattD at 1:43 PM on September 29

Which makes perfect sense for treatments that involve equipment, supplies, etc, rather than being primarily or solely a person-to-person interaction for a prescheduled period of time. There isn't anything a therapist can do to make an hour pass within 45 minutes.

My only concern about appealing here would be that by making a stink you may cause them to review previous payments this plan year and attempt to claw back the excess already paid if the fine print allows for it. If you have looked and found that your provider's charges are in line with what everyone else is charging, there's less risk here since there is a good chance you can prevail on this point, if not with the appeal with a complaint to their regulator. If your provider is indeed more expensive than most/all of the others, well, I'd probably just be happy they'd not given me trouble about it before unless I was absolutely certain they couldn't then offset future payments against the past overpayments.
posted by wierdo at 3:10 PM on September 29 [1 favorite]

You're correct wierdo, it's for therapy, so a diminishing "reasonable and customary" price doesn't make sense. This article by a psychotherapist had some pointers. I'll call the insurance next week (when their phones are back up... *headdesk*) and report back to the thread in hopes that my experience helps someone in the future.
posted by rogerrogerwhatsyourrvectorvicto at 5:35 PM on September 29

Reimbursement rates for therapy have actually been declining over the years, which is one reason so many therapists don't accept insurance. So it's totally possible that the insurance company has decreased its rates, but you should still argue with them about it.
posted by lazuli at 8:48 AM on September 30

« Older How do I find a job and move from 1000 miles away?   |   African American history resources for pre-school Newer »

You are not logged in, either login or create an account to post comments