Ellen PhillipsI had surgery about six months ago, but my insurance company didn't pay what I thought they should. I'm out several thousand dollars that I can't afford so I need to file an appeal. I know you've advised how to be sure the patient isn't charged more than accurately but I can't find where you talked about filing an appeal. Help, please. - David Denied
Dear Mr. Denied: I'm very proud you're taking this particular bull by the horns and not allowing Big Business to pick your pocket without a fight. Last month's column about rising 2017 health care insurance premiums is scary enough without Ira and Iris Insurance taking more than what they see as their "fair" share.
So what should you do to retain what's yours? For Obamacare naysayers, appeals are much more successful now than they used to be.
(I recall a specific case back in the 1990s before I shut down Ellen's Poison Pen. My client delivered premature twins with an extremely difficult delivery; the hospital bill ran into the hundreds of thousands but the insurance company zipped up its wallet way too early leaving Mom and Dad responsible for over $100,000. She attempted numerous times to contact the hospital administrator, as well as her advocate within the insurance company. While these authority figures sounded sympathetic, the poor - literally and figuratively - new parents continued to receive dunning notices that almost turned into a legal battle. Long story short, when I finally got involved, I did as I always advise readers and audiences to do: write that professional letter of complaint to the Head Honcho, utilizing all the methods I've preached, and copy all applicable regulatory agencies. Six months later (Never Give Up), not only did Mom and Dad walk away owing the hospital nothing, but all "their" correspondence resulted in the hospital and insurance provider finding several hundred dollars they actually owed the parents! Note: All of my clients over the years signed the letters I ghost-wrote for them so whatever compensation Big Business offered went into the consumers' pockets.)
Obamacare or the Affordable Care Act requires that any time a medical provider denies an insurance claim or payment, it must do so in writing and spell out the exact appeals process. Moreover, the ACA mandates that, even if you lose your appeal, you can still appeal that one to a non-insurance third-party entity, such as the state insurance commission. Currently, up to 60 percent of appeals are won. While this number is fantastic, it's no guarantee any of us will be in the lucky percentage so we need to increase our odds of winning.
If you aren't up-to-date, please check your coverage. Too many of us think we know what's covered and what isn't, only to discover at an inopportune time that we don't but should've. Okay, a quick true-or-false quiz: Medicare pays for routine tetanus and flu shots. For those who answered yes, you're only half correct so get out your checkbook to pay for the tetanus shot. Only if it's deemed an emergency will the shot be gratis; on the other hand, yearly flu shots fall under Medicare's Wellness program so you'll pay zippo. Most insurance companies don't pay for elective surgery, unless the "election" is really necessary - an eyelid lift if one's sight is affected or a breast reduction to help chronic back pain are two instances and even then, all surgeons won't necessarily agree the procedures are medically necessary. Be prepared for any eventuality before it comes up; either read the policy or call your insurance company to confirm coverage and/or coverage limits before a situation arises.
Nag, nag, nag from yours truly continues with respect to watching for errors in your statements: medical (Explanation of Benefits/EOB), credit card, utility bills or whatever. Even though some of you may wish I'd shut up, I simply cannot stress this eyeballing enough. Too many errors get filtered in statements, whether by mistake, calculation, or sheer stupidity and the patient or customer must be the one to catch the mistakes. Again, be certain you always insist upon an itemized list of every service you receive from a medical provider, check hospital codes to ensure the hospital or physician has submitted the correct one; otherwise, a simple $129 surgical dressing could turn into a $5,000 metabolic blood test. (Still exorbitant for this particular test but more understandable than a bunch of gauze and a few strips of surgical tape, for Pete's sake!)
Watch your network. Obviously, we need to stay in-network if at all possible as we get much more bang for our buck with approved medical providers. Unfortunately, while this isn't always possible for what ails us, the insurance company still charges us part or all of the cost. Appeal this decision if you can show an emergency necessitated the service or if the insurance company can't meet your need. The latter scenario really occurs more often than one might think; for example, your child needs specialized brain surgery and you must travel out-of-city or state for the closest provider who performs the intricate surgery. (To avoid an unnecessary appeal, however, obtain preauthorization for out-of-network services along with all documentation to support your request, such as for the long distance surgeon, and the real kicker - as many medical experts as possible who back up your claim, preferably in writing.)
Contact Ellen Phillips at consumerwatch@timesfreepress.com