How do you get a health insurance company to pay for a claim after it was initially denied?

Question

My wife was having severe headaches and feared she had a serious medical problem. I took her in to the emergency room, they gave her a shot and a perscription and diagnosed it as sinusitis (sp). The insurance company is claiming the visit was unneccesary. To me, it seemed a necessay precaution. What can I do to get them to pay up?

I'm in Pennsylvania.

The company is Health Assurance. I changed jobs so I am no longer with them. They stated that the ER visit was unnecessary because the condition existed for 10 days prior. However, her condition became very severe on the night we went to the ER and our primary care physician was not available to see her. They did give her a shot for her pain that night at the ER which should serve as evidence that she was in intense pain. Also, I do not have a copy of the medical records from that visit but I am calling the hospital tomorrow in order to obtain those records.

Answer 1

It's common practice to deny claims like this, especially when the ER billing came through with a diagnosis of sinusitus. But you need to appleal this.. in writing. Call the number (should be oon the back of your card) get the address, and lay out the facts...

Your wife had been suffering with this for approx 8 - 9 days.. you both felt that it would pass.. on the 10th day she was in sever pain, after attempts to contact her family physician your only other option was the ER, as you had no idea what was wrong with her.

After taking her to the ER, they were able to diagnose her. This was a situation that , in hindsight, we should not have tried to allow your wife's imune system to handle on her own. But you had no idea that it would worsen as rapidly as it did.

Enclosed are the bills for service. According to the medical plan coverage does exist for these charges. Please review your decision to extend coverage.

You may have to 2nd and 3rd request it.. Make sure you cc: the hospital, doctor, etc.. so they see that you have it under control. The company is a good one.. It's just common practice.

However, if you were a doctor and could have figured out what was wrong with your wife.. you wouldn't need them. :)

Answer 2

You have to call your insurance company. It's a tedious process, but it's worth it. You have to file a grievance. Some people before me are saying to write a letter, some are saying you need documentation..... You unfortunately haven't told us who your insurance carrier is, what your wife's EOB said (all insurance company's issue EOB's or explanation of benefits when a claim is processed, and they use codes to explain why the claim was denied along with a description.) The reason why you must tell us this info in order for us to answer correctly and accurately is because an Emergency can never be deemed un necessary, they could deny a claim for a Urgent care center, because urgent care centers are contracted with the PPG, and if your physician was available to take you as a patient, then that may be why they are denying it. If this was a real emergency and as long as you went to a contracted ER you should be fine. It could be a billing error, the ER could have used the incorrect medical codes when billing the procedure to your insurance, it could be anything really. You also didn't say who is denying the claim, usually ER services are the responsibility of the Insurance carrier, but there are some company's (and contracts for that matter) that have the PPG or medical group responsible for certain services..... So I guess what I'm trying to say is everyones advice on this one can be correct but without knowing these things one person really can't answer this question accurately.

Answer 3

You can appeal the claim in writing (and you'll want to do so.)

But before you do, I recommend you look into the Insurance Commissioner's ofice of your state. Most have some kind of ombudsman, or assistance office for managed care programs. You can almost always find this info on the state's web site.

While the commissioner's office may not be able to get specifically involved in your claim (they don't always and particularly not when there's no pressing medical need), they do keep statistics on reports against insurance companies doing business in the state.

The insurance companies hate to hear that you've contact the insurance commissioner's office because they know that the statistics are being compiled and that may cause an audit (or worse, expulsion from doing business in the state.)

When you then appeal the claim in writing, be sure to mention that you've contacted the commissioner's office (and give the exact name, for instance in Virginia, it would be the Virginia Insurance Commissioner's Ombudsman for Managed Care.) You may be wielding a big sword for a small problem, but you'll also be making them aware that you know your options.

Good luck!

Answer 4

Well... You're in a pickle. You're going to need the help of the hospital she was seen at.

First, don't appeal it on your own. You will only have the opportunity to appeal 2 or possibly three times. You don't want to exhaust your appeal options...

I need to know what state you're in to help you completely... But, all in all this is what you need to do.
The hospital wants to get paid... So does the doctor. They will help you... Most states define an emergency as;
acute symptoms of sufficient severity (including severe pain) such that the prudent layperson would believe that the absence of immediate medical attention could reasonably be expected to result in (a) placing the patient's health in serious jeopardy; (b) serious impairment to bodily functions; or ( c ) serious dysfunction of any bodily organ or part.

So, if she was in a significant amount of pain, its an emergency. The doctor or hospital should submit her medical records for the ER service to your insurance company, with an appeal letter.

Most likely, the info on the claim form didn't have enough emergency based medical info. Don't worry. It'll be ok. Let me know if you need help.

Answer 5

With your insurance EOB, (the papers you should have received after the claim was initially processed) you should see on the back or near the end of the paperwork, a way to appeal the decision. Usually it means you need to write a letter and mail it to the insurance company within a certain time frame. Write in the letter what her problems were and the severity, and that it was medically necessary (maybe other approaches were not helping). You can also contact your state's dept. that oversees insurance, and file a complaint with them.

Or you can also ask over the phone what your insurance companies appeal process is.

Answer 6

Call the insurance company and ask for their appeals process - including contact name and address or fax number. You will have to write an appeal letter to them.

If you went to the ER during normal business hours, or if the headaches were ongoing for several days, technically, the insurance is right - this could have been handled by your normal physician during normal business hours. (If you or your wife said anything about the headaches being ongoing for more than a day to the hospital, don't waste your time appealing - if the insurance company subpoenas the medical records - which they can do legally without asking you first - you'll lose anyway. ) BUT, if the headache was sudden and severe or got worse over a period of less than 24 hours and your normal physician wasn't available - like in the middle of the night or a weekend, then you have a case to appeal.

You have to be able to document in a letter to the insurance your exact reason for going to the ER and ask them to reconsider the denial. Keep a copy of this letter and note the date you send it in. Follow up on the status of the appeal 10 days later to make sure it's been received and being worked on, and ask for an approximate finalized date.

Sadly, because people have abused the ERs over the years - by going for non-emergent things like diarrhea or something minor like that, many insurance companies will make the legitimate claims have to jump thru hoops to get them paid.

(I was once in the local ER with my mother who had a severe asthma attack and was transported in by ambulance. While she was being worked on - and if we had waited 15 minutes longer to call 911, she would have died - this woman whose kid was constipated was all p*ssed off that she had to wait. My father had to physically restrain me from going to punch this woman.)

Answer 7

Try resubmitting the claim. Some companies have a policy of denying a certain percentage of claims on the first try.
Most companies have a plan for appealing denied claims--learn it, follow it. Get a supporting doctors statement to go with it.

Answer 8

You have to talk with them and stay on them.

I had an EMERGENCY c-section and the epidural was deemed unneccesary. We fought it, and they eventually covered it.

There's a number on the back of your card as to whom to call. You never know until you try, and if you really stay on top of it you may win.

Answer 9

You can't force them to pay. You can appeal their decision or file a grievance. Make sure you have the physicians documentation and send it with your appeal.

Answer 10

talk to a rep and see what can be done.........if that doesn't help than file an appeal with the insurance company