Does anyone know how to write a letter of appeal to an insurance company?

Question

So in July I ended up loosing my baby at 14 weeks pregnant, i had to get a D & C done but my primary doctor was out of town. They had another doctor do the procedure and the doctor was covered but my insurance id denying the claim for the hospital saying that they are not providers for that Hospital. my problem is that i did not set up the surgery for the hospital my doctors office did the nurse asked me, the day i found out, What hospital i would like to go to have the surgery done at? My exact words were "I don’t care as long as they take my insurance" went home and the next day i had everything done. Now i don’t know what to do i have this huge medical that i can pay for? Does any one know how to go about writing a letter of appeal? Thanks for your help.

Also the doctor had told me that it was an emergency and that it needed to be done immediately but i couldn’t go threw with it on the same day i found out. I lost the baby at 12 weeks it was 14 weeks when i had the D&C done. Thanks

Answer 1

I'm so sorry for your loss. (How much does it suck to have this added on to it? Geeez.)

First enlist the help of both your doctor and the doctor who did the procedure. They'll probably be willing to help - since it's going to them paid. Tell them you'll keep them in the loop about what's going on and if they can help you with medical documentation, you'd REALLY appreciate it!

Second. Call the insurance and ask for the appeals address - including any contact name and phone number, if applicable. Ask them what they need - sometimes, they just want a copy of the doctor's notes, sometimes they want a pint of blood. (Almost literally.)

Next, gather the information - get supporting letters of medical necessity from the doctors. From your regular doctor - a note of that the covering doctor was covering while your regular one was out of town. From the covering doctor - a letter stating that it was an emergency and needed to be done sooner than later - and their reason why. The more documentation, the better!!

You write a letter telling the insurance that you are asking them to reconsider the denied charges because it was medically necessary and the attached documentation will prove it. KEEP COPIES OF ALL OF THIS!!!!

Send them to the appeals address, with a return receipt requested. Once you have that reciept, start calling to follow up ("check status of the appeal") about two weeks after they receive it. You may have to be a royal pain in the you know what to them, but squeaky wheel gets the oil! I find if you drown the insurance with paperwork showing them you're not going away, they give up and give in.

Good luck!!

Answer 2

I'm sorry for your loss.

The problem with you is that it was a scheduled procedure. If they had whisked you out of the doctor's office and taken you directly to the hospital, you might be able to get by saying that you had no choice and it was an emergency.

But, since the procedure was scheduled a day in advance, that's probably going to sink your appeal. From the insurer's perspective, you are the one who has the ultimate responsibility to know your provider network. And the insurer could realistically argue that you should have been aware of your hospital network...given that you would have (should have) selected your OB/GYN office with the consideration in mind that they would perform services at network hospitals.

So, I will advise you not to be optimistic about your chances for appeal. However, you can certainly give it a shot and this is how you would do it:

Write a clear, concise letter detailing the facts of the situation. Attach supporting documentation from your medical provider's office (medical records, etc.). Make sure that you send the letter within the appropriate appeal time frame - if you wait to long, you could lose your right to appeal the claim at all. (A common appeal deadline is 180 days from the date that the claim initially denied - you can confirm with your insurer specifically what your appeal deadline is.)

After you've done that, all you can do is wait. As I said, your insurer will unfortunately have valid reasons to reject your appeal, given that the procedure was scheduled a day in advance. (If it had been an "emergency" according to the insurer's definition of emergency services, you wouldn't have been able to wait overnight for it.) But, it certainly couldn't hurt to give it a shot.

If your appeals are denied, I'd try negotiating with the hospital. They might be able to work with you on your bill.

Answer 3

I'm sorry about the loss of your unborn. Sad to say, your appeal to the insurer will probably not get you anywhere. Generally, they only consider 'paying out of network' when you have an emergency and an IN NETWORK hospital is not available due to your location at the time of the emergency.

The doctor's office involved apparently made an error, but that's not the fault of the insurer involved. I highly doubt that the doctor's office will take responsibility for the uncovered costs due to their error. In the end, it's the responsibility of the insured to certify that the care they receive is within the network of covered providers.

Answer 4

You're in a rough situation. The procedure was not "emergent" therefore you were expected by the insurance to go to a covered facility. You are expected to have some reasonable knowledge of what hospitals in your area accept your insurance. You may not be in a position to force them to pay - and may want to discuss this with an attorney. I am sorry that this happened, but part of being a responsible adult is being an educated consumer and that includes your health care insurance and medical coverage.

Answer 5

Oh, bummer, I'm sorry for your loss.

Well, the bottom line is, it's not the nurse's responsibility to verify which hospital is in network for you - it's yours.

Doctors can have operating priveleges at multiple hospitals - and at least one of them should be in network.

If it were me, I'd appeal saying, there's this in network doctor, we're at HIS hospital for the procedure, this needs to be considered an in network hospital for the procedure. Then you have to sit back and hope they agree.