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> Anybody Here Have Experience With Medical Claim Appeals?
Tara
post Dec 19 2017, 09:00 AM
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So a little background here. Doing anything that required a little bit of exertion caused my heart rate to jump dramatically high. I decided to go to finally go to a cardiologist who did an EKG, stress test, 24 hour Holter, and an echocardiogram. All the tests came back inconclusive so the doctor just kind of told me that is how my heart works. I wanted to get a second opinion so I went to another cardiologist. He had me get a CT scan of my heart to rule out an issue he told me about that the arteries and veins are switched or something like that. He said it is super rare but good to rule it out since the test was cheap. He also sent me to an electrophysiologist who wanted to do a 7 day heart monitor. After the results of the 7 day monitor my cardiologist put me on a beta blocker and now my heart rate is under control.

The 7 day monitor was denied by my insurance because it was found to be "not medically necessary" so I sent in an appeal with my whole situation and references to research papers showing 7 day monitors are more accurate in finding an issue than a 24 hour monitor. Denied again. I want to send a second appeal but I don't know what else to tell them that I already didn't. I can send it for an independent review with the Office for Consumer Health Assistance but if I do that I am not eligible for a second appeal. I figured I would do the second appeal and then send it for the independent review.

Any tips here?


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cake
post Dec 19 2017, 05:32 PM
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Sorry I donít have the answer.
We ended up in court over issues with two different insurance companies. Won both but it was long and aggravating. In our cases the dollars were worth getting lawyers involved.

Iím very glad your second doc found the source of the issue and itís under control.
Best of luck with the appeals and I hope someone on here can give you good advice.

Health is the most important thing!!
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CHADW
post Dec 19 2017, 05:59 PM
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Agreed, Iím glad you have your health figured out. I wish I had some answers for you on insurance but most of my experience has been insignificant but a pita. Did you pay the bill yet and if so, how?
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kinnsella
post Dec 19 2017, 06:33 PM
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Glad you got it sorted, who is your insurance co?
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jhbchess
post Dec 19 2017, 07:18 PM
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I have not done this myself but attacking the definition of medically necessary is recommended by a couple of decent guides to appealing:

https://www.carcinoid.org/for-patients/gene...-their-weapons/

http://guides.wsj.com/health/health-costs/...surance-denial/

Sample letter outlining attachments to provide back to insurer: http://www.ncdoi.com/Consumer/Health/Docum...ry%20Appeal.pdf



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US/UK-Diablo
post Dec 19 2017, 09:11 PM
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In the current environment you should be happy you have any health insurance.
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donblackie
post Dec 20 2017, 05:46 AM
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Im not sure I can be much help here other than the fact that I had to appeal to get my 2 level cervical disc replacement surgery done this year but the surgeon's staff did all the paperwork and process on the appeals.
Is the cardiologist's office not well versed in these types of appeals?

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Tara
post Dec 20 2017, 08:05 AM
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Thanks guys! The insurance company is Anthem Blue Cross Blue Shield. I am contacting the doctor today to see if they can help with anything. I mentioned the definition of medically necessary in my first letter but that didn't do anything. It is not enough to get a lawyer but enough to be an issue. I have not received the bill yet but when I do get it I'm not sure if I should just pay it and continue to fight the claim or not pay and fight the claim.


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Chipster
post Dec 20 2017, 09:42 AM
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QUOTE (US/UK-Diablo @ Dec 20 2017, 02:11 AM) *
In the current environment you should be happy you have any health insurance.


Not sure how it is helpful or relevant to make a political comment in this thread.

Good luck Tara. I believe you have some time before paying the bill and p4obably just something to discuss with the doctors office before paying.


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emanon
post Dec 20 2017, 10:11 AM
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QUOTE (Chipster @ Dec 20 2017, 09:42 AM) *
Good luck Tara. I believe you have some time before paying the bill and p4obably just something to discuss with the doctors office before paying.


I don't have a ton of experience here, but how the billing people in the docs office "code" it when they submit the claim can have an effect as well. It might be worth discussing with the doc as well, beyond the direct medical necessity aspect.


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SYNYSTR
post Dec 20 2017, 01:09 PM
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I had some ancillary items not covered by BCBS in the past. I ended up negotiating with the provider themselves for a substantially reduced rate.

Not nearly as serious as cardiology, but worth my effort.

Kudos to you for being proactive with your health.
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yellomurci
post Dec 20 2017, 02:33 PM
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QUOTE (SYNYSTR @ Dec 20 2017, 04:09 PM) *
I had some ancillary items not covered by BCBS in the past. I ended up negotiating with the provider themselves for a substantially reduced rate.

Not nearly as serious as cardiology, but worth my effort.

Kudos to you for being proactive with your health.


I did the same when my insurance refused to pay a bill (my fault as the particular provider was not in network and I did not check as the hospital they work in was in network)
If I remember a 10k bill was reduced to about 6k, I did have to do a bit of finagling but was worth it in the end.
Good luck and as others have said well done on sorting your medical problem.
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CHADW
post Dec 20 2017, 05:56 PM
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To build on some thoughts already mentioned, the doctorís price will be completely different if you are paying vs them billing insurance. I would have a conversation with the doctorís office that they need to help you with the appeal or expect to heavily discount the test to you.
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Tara
post Dec 21 2017, 05:34 AM
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The doctor is going to write a medical necessity letter for me that I can send in. I'm pretty sure it is a third party company that supplies the monitor because it is not the doctor's office on the EOB. if the second level appeal does not work I will send it to the independent review board. If it is still denied I will work with negotiating with the company.

I think having a heart attack would be more expensive than the monitor, but what do I know?


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Fortis
post Dec 21 2017, 01:36 PM
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Tara I am very sorry to hear about what you are going through but I am VERY glad you got properly diagnosed and that you have it under control.

Itís trully ridiculous and inconceivable that a very wealthy and resourceful 1st world country doesnít have a proper system in place for looking after the health of their citizens, health should be priority number 1, if you sick you canít function if you canít function you are a non revenue producing a liability and a drain on the system.

One thing I can say about where I live, I never worry about healthcare is it perfect maybe not but at least they will not let you die in the street and when they save you from dying they will not smash you with a bill that you wish youíd rather be dead LOL

I think I will stop complaining about our ridiculously high taxes and car prices.
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CHADW
post Dec 21 2017, 05:05 PM
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I donít know, Fortis, you can pay for a lot of medical expenses for the premium you pay for just one Lambo.
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Carter
post Dec 21 2017, 05:45 PM
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QUOTE (Fortis @ Dec 21 2017, 04:36 PM) *
Itís trully ridiculous and inconceivable that a very wealthy and resourceful 1st world country doesnít have a proper system in place for looking after the health of their citizens, health should be priority number 1, if you sick you canít function if you canít function you are a non revenue producing a liability and a drain on the system.


Geez! Why should your health care be someone else's priority? Talk about ridiculous.

QUOTE (Fortis @ Dec 21 2017, 04:36 PM) *
One thing I can say about where I live, I never worry about healthcare is it perfect maybe not but at least they will not let you die in the street and when they save you from dying they will not smash you with a bill that you wish youíd rather be dead LOL


Doesn't happen here either. Geez man what kind of people do you think Americans are?
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Fortis
post Dec 22 2017, 07:19 AM
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QUOTE (Carter @ Dec 22 2017, 11:45 AM) *
Geez! Why should your health care be someone else's priority? Talk about ridiculous.



Doesn't happen here either. Geez man what kind of people do you think Americans are?


Geez!! Chill man you might end up having heart problems and trust me you don't want to risk it in America LOL J/K don't be so defensive we are just making conversation here.

To answer your first question, I was talking about your government, that's why you pay taxes, I did not say someone else's priority, your government should handle that

As for your second statement, I get my information just like everyone else from Lambo Power, jokes aside, why would Tara even have to make such a post if this wasn't an issue?

She would never have such problems under our healthcare system she would simply walk into a state hospital and have all her procedures done, unless they are elective, as I said no system is perfect but here I never worry about our healthcare and/or its cost, if you broke you are covered if you have money you are covered and it's not expensive either (see if you broke you are covered statement) and yes I want someone else to pick up the tab, the government, because they are using my God damn money so they better spend it on me when I need it.

Every single citizen of this country is covered under Medicare you can also select to buy private health insurance, in some instances the government makes sure you actually do that LOL.

Once you reach a certain wage bracket you have two options, pay a medicare levy or purchase private health insurance, the choice is yours, in certain situations you do have some out of pocket expenses but they are really insignificant, that's the reason why I am saying we never really worry about healthcare here.

If things are great why is Tara having to fight her insurance company, she has heart problems which is no laughing matter she wasn't requesting cosmetic surgery?

Also just read on LP how many people are complaining about the cost of their health care and how many employers are complaining about the escalating costs of their health insurance liabilities.

If things are great, everyone's covered, the healthcare system is working perfectly fine running in all cylinders and everyone is happy please accept my apologies for my ignorance!



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Fortis
post Dec 22 2017, 07:20 AM
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QUOTE (CHADW @ Dec 22 2017, 11:05 AM) *
I donít know, Fortis, you can pay for a lot of medical expenses for the premium you pay for just one Lambo.


You are a VERY wise man! sad.gif

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Fortis
post Dec 22 2017, 07:31 AM
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Carter I did a bit of reading:

https://www.investopedia.com/articles/perso...ould-happen.asp

Without health insurance coverage, a serious accident or a health issue that results in emergency care and/or an expensive treatment plan can result in poor credit or even bankruptcy. Dylan Roby, assistant professor of Health Services Administration at the University of Maryland School of Public Health, tells Investopedia, ďA cancer diagnosis, car accident, or even a broken leg can cost thousands of dollars out-of-pocket.Ē

My comment even though it was done in jest doesn't seem that far fetched

"One thing I can say about where I live, I never worry about healthcare is it perfect maybe not but at least they will not let you die in the street and when they save you from dying they will not smash you with a bill that you wish youíd rather be dead LOL"
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