We have a couple of doctor bills that weren't covered fully by our insurance company and so I want to try an appeal. I am not sure how to word things to get a good result, does anyone have any experience in writing about this sort of thing?

The hospital we went to was a participating hospital, but the anesthesiologist and emergency room doctors were not in the plan. You aren't given a choice when you go there, you just get whatever doctor is on and there are like NONE in that hospital who take our insurance. Our insurance company is based in NY, so there really aren't many doctors for us to use around here.


Any advice would be appreciated, we really would like to get these taken care of.

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"A true friend is someone who thinks that you are a good egg even though he knows that you are slightly cracked." ~ Bernard Meltzer

You can go about it several different ways. I don't know which would be easier or quicker but here goes:

1) You need to get a letter of medical necessity from the anesthesiologist and the ER Drs. for their services, it would be beneficial if you could get something from the hospital indicating that you received services and were not given the option of choosing the physician(s) who provided care, and that it is the hospital policy that patients are required to be treated by whatever doctor is on call at the time of admittance. Then submit all this to the insurance company with a request for review and appeal.

2)Sometimes, all the insurance company needs is a letter from you disputing/appealing their decision, as they don't look at the medical records, just whether the doctor was in network or not. With an appeal/dispute they are required to get the medical records and review them and USUALLY will reverse their decision after reviewing the records. If choosing this route. Recount the events in as simple a manner as possible. Make sure to include names, dates, etc. And request that the medical review staff review the medical records for medical necessity and to reconsider their denial of services.

3) Contact your state insurance commission and ask them the steps you can take to file an appeal. Some companies provide pre-printed fill-in the blank type forms.

Best of luck. Filing an appeal can work. I had a similar situation and got the matter resolved so that all I had to pay was the usual and customary co-pay and deductible (which is all I was asking for!)

PM me if you think I can offer more specific help...

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Mental that one, I'm telling you. ---Ron Weasley, "Harry Potter and the Chamber of Secrets"

Good luck, dealing with insurance companies sucks! I am a pretty good writer when it comes to letters - if you want to start the letter so that I can get a premise, I'd be happy to give it a shot for you. PM me for my email address if you're interested.

I agree with poster marilynk. Could be all you have to do is point out about the participating hospital and available doctors there. I'm assuming this was an emergency situation? Not something thought out ahead of time?

Reminds me of the time DH was having outpatient surgery. All the surgical suites were occupied in the outpatient facility so they wheeled him across to the main hospital. Then tried to charge us for using the main facility instead of the ambulatory facility. It wasn't our choice, it was the hospital's.

We are not currently dealing with anything similar but we did just get through with a big fight with our automobile insurance company. We finally received a full settlement for our totalled vehicle.

Things did not start moving for us until we started direct emailing the supervisor over the claims department.

So, my advice would be to carbon copy all letters to the top banana.

Hope it works out. That is such a hassle.

I spoke to someone at the insurance company, which is actually the union I believe and they just said to write a letter and explain that there is no one in our plan in the area. The hospital is in the plan and it is only one of 2 we really are close to and where dh's cardiologist works out of, so that's where we have to go for his heart problem.

Long story short about why we went there, DH has a heart condition called Atrial fibrilation, his heart goes out of beat and it went out one night when he was chasing the kids up the stairs. We call the emergency line at his Cardiologist's office and they said go right to the emergency room. He stayed over night and had a Cardioversion (shock him with the paddles) the next morning and was released. Not a big deal for us, but something that has to be watched because it COULD cause a bloodclot or stroke.

If you look on the website for emergency room doctors, there aren't ANY within 20 miles of the hospital! Same with the Anesthesiologist!

So to go where the heart doctor is in the plan and the hospital, we have to go where no one else is. If we went to a place where everyone participates, we would have to drive over an hour!

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"A true friend is someone who thinks that you are a good egg even though he knows that you are slightly cracked." ~ Bernard Meltzer

Hi- I just read your post the same thing happened to me when I had my daughter I ended up having a c section. . If I remember right- we are talking 5 years ago I called when I found out why and becuase it was participating hospital they had to cover it- not sure how exactly it was worded to me but it should defintely be covered. Don't know who you have but we had blue cross at the time

Justin

This is Magnacare, don't think I;ve ever heard a good thing about them. Our pediatrician actually stopped taking that insurance because they were so slow in paying, but have since gone back.

The big problem is that they are more of a NY based company and we are in northern NJ. Our kids were both born in a NY hospital over almost an hour away so our OB/GYN and hospital stay would be covered, it was the only place that had both. No anesthesiologist there either though.


They SHOULD make it a rule, if you work at a participating hospital, then you have to participate too.

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"A true friend is someone who thinks that you are a good egg even though he knows that you are slightly cracked." ~ Bernard Meltzer

have you talked to your HR person. We were having problems getting insurance to pay a bill and my first step was to call the insurance who started the process. I didn't need to write a letter, it was all done by phone. The insurance then arranged a 3 way call with the HR deptment and the doctors office. It was all handled by phone and they did pay the charge.

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Not sure if you got it all straightened out yet or not but I thought maybe this info will help. I have worked for health insurance companies for well over 10 years now from entry level to management. And I can tell you nothing annoys me more then a situation like this.

That being said, at every company that I worked for and dealt with, it has always been common practice to pay out of network bills associated wiht an in netwrok ER visit or in network hospital stay at the in network level as well. The problem comes in to play that when a bill is submitted, a "computer" just automatically processes the claim as it is. It doesnt do the common sense thinking that you or I would do and say well, the hospital was in network so let me pay all these other bills in network. All you should have really had to do was call the insurance company and explain it to them. In a rare case, they may say, well prove that it was an emergency over an elected type of service but none the less, you really shouldnt have a problem getting the insurance company to readjust the claims associated with that hospital.

Now I do want to add that I work mainly in self insured business so it really is up to each and every group unlike fully insured where the insurance company themselves make the decision. There was one client, a very large hospital, that actually refused to honor this type of situation. They basically said that if the ER doctor, lab etc was not in network, then it was to be paid out of network. No lever of appeal was going to make this client change their minds and for that, they had a lot of very unhappy employees. But I guess they had their reasons for doing this, I just still havent figured out what they are.

I hope I helped, like I said, I have been involved in health insurance for a long time and while things may seem common sense, nothing in insurance is ever balck and white, there are always exceptions etc to every rule and policy.

Good luck and if you have any specific questions, just ask.