The following story was submitted by a reader:

My dad had brain surgery this summer. He had to have fat tissue taken from his stomach so they could use it to plug up the area of the incision.  The hospital defines the procedure of removing the fat tissue from his stomach as liposuction…well guess what…insurance companies don’t pay for “cosmetic surgery”!  So, sure enough, he just got the full bill for $1900 for that part of his brain surgery!  He’s currently battling this trying to have the hospital reclassify this procedure or the insurance company understand he wasn’t on the table just to lose a few pounds (in reality I believe he lost just a few ounces from his stomach).  It sure would be nice if there was a little intelligence applied when determining a claim should be denied…like noticing this procedure was done at the same time as removing a brain tumor.

When you read an absurd denial like the one above, it’s makes it impossible not to assume the insurer is just testing the patient, seeing if they can slip one by and walk away a little richer. Maybe they assume a really sick person doesn’t go through their  mail diligently. Or that the patient is too scared, or uninformed and will just pay everything that is asked of them. If 1 out of 20 people go along with their assumption, guess what, the insurance company wins.

Health insurance companies have an appeals process. The first requirement of any appeal is for the patient to present it to the insurance company within a limited number of days. This number can vary from company to company, some are 180 days within receiving the letter of denial, some can be as low as 60 days. Patients need to check with their insurance provider. Asking the doctor(or hospital) to directly contact the insurer is worth the patient’s while. In the above mentioned case one would hope the hospital could make a phone call or two, or reclassify the procedure as the reader mentioned, and sort this out immediately. If they cannot resolve it, move forward with drafting a letter. Insurance companies will give the option of appealing over the phone—don’t do it. A paper trail is essential, have everything documented, including the specifics of why the claim is denied and what alternative(s) the insurer can prove to be a viable in place of what was performed.

Once the letter is mailed, expect a response letter stating the appeal has been received within two weeks. If one is not received, call and inform the insurer, and send another copy of the appeal. The insurance company will issue a decision within 30 days. If at this point the claim is still denied, it can be taken to the state, this is referred to as an external appeal. All states have Insurance Laws, and some even provide programs to assist the patient in preparing their grievance. If the state finds in the patient’s favor the insurer must pay the claim.

What was just summed up in a two paragraphs, is a painful exercise in patience and stress management. In an ideal system, as the reader said, their would be intelligence applied in this and other cases like it. But that isn’t our current reality, reality is hours and hours on the phone, letters mailed, and endless aggravation. Through all this remember the worst thing to do is buckle under the weight of an over-bloated, impersonal system. Motivate yourself to be the person who demands better.

Please share your stories here.

Post to Twitter Tweet This Post