appealing health claim

Appealing an Insurance Claim

I couldn’t believe I racked up a $93,000 bill. (Click here to read the full story.) Even worse, $15,000 was denied by the insurance carrier and was considered out-of-network services. Spoiler alert, you can appeal a health insurance claim. I was recently diagnosed with Vestibular Neuritis, an inner ear disorder that may cause a sudden onset of vertigo, dizziness, balance issues, nausea, and vomiting. As a recap, here are the events of that day:  

  • Wake up.  
  • Feel sick.  
  • Get worse.  
  • Call Miami Dade Fire Rescue.  
  • Get subjected to multiple tests at an in-network emergency room.  
  • Enjoy a three-night stay at an in-network hospital.  

While the facility I was transferred to was in-network, the ER (Emergency Room) doctors were not. Most hospitals do not employ their emergency department physicians or anesthesiologists. Instead, the hospital has a contract with the doctors, who then bill the patient. While the doctors bill the patient separately, patients can and should appeal the claim if treated at an in-network hospital. The bill can be reversed and covered or significantly reduced. 

A person with no medical background may find the appeals process overwhelming, which it is. It takes time and effort to appeal a decision. But it is worth it. According to Jennifer Obenchain, case management director at the Patient Advocate Foundation, in Hampton, Va. 65% of appeals are successful. In my 35 years in the industry, I’ve personally experienced the headaches of dealing with claims and have guided my clients through the system as well. To determine if the claim was processed correctly, I always recommend reviewing your EOB (explanation of benefits) first. If you believe your claim was incorrectly handled, start your appeal immediately. You can try to deal with the insurance company directly or, better yet, contact your benefits advisor for assistance. 

Don’t go at it alone

Fortunately, we have a dedicated claims department that handles these types of situations. So, I contacted our in-house team to sign a HIPAA (Health Insurance Portability and Accountability) form and start the process. Her next step was to contact my carrier’s customer service. She wasn’t satisfied with their response, so she reached out to our carrier’s broker support team and informed them that this service was performed at an in-network hospital and needed re-processing as such. They agreed with her findings and sent the claim for review.

We were excited, as this seemed promising. Then the following week, she was notified that the claim had been handled correctly and there was nothing we could do. At that point, we began the appeals process. 

The health insurance claims appeal process:

When you begin an appeals process, you want to contact the provider and place the amount due on hold to avoid collections. Eager to start the process, many forget this first step. Next thing you know, you are bombarded with bills and letters. Having your account go into collections is not only bad for your mental health, but it can also wreak havoc on your credit. 

Finally, after several weeks of continued follow-up, the claim was processed and approved correctly! As I met my deductible for the year, which was $1,500, my responsibility was a 30% co-insurance of the provider contracted amount, which came to $2,500—staying in-network and appealing the claim lowered my cost by thousands of dollars. I am so grateful to our in-house claims advocate for her dedication and love for what she does! I can only hope that you have access to this valuable resource.   

By Ileana Miranda, Employee Benefits Consultant, Sapoznik Insurance, a World Company