Need advice writing a Health Insurance appeal letter - Tilted Forum Project Discussion Community

telekinetic · 12-17-2008, 08:45 PM

Background: I had sudden severe abdominal pain, so my wife drove me to the nearest hospital (accross the street), where they performed an emergency appendectomy. Three weeks later, I had stomach pain again in the same area, called my surgeon, and he advised I go to the ER as soon as possible for diagnostics. Total bills for both events = $40,000+ ($32,000+ and $8,000, respectively)

The 'gotcha': My insurance (Humana POS) considers this hospital, and all of its services, 'out-of-network'. The difference in deductible between in and out of network is substantial ($1500 vs $4500).

The footwork so far: I spoke with the billing agent at the hospital, she suggested I write an appeals letter to the insurance company requesting that, due to the emergency nature of the services, they be billed as in-network. I have copies of all my medical records to send in as well.

The goal: Get all expenses covered under the in network deductible!

The questions: Has anyone written a successful appeal letter for this or any other similar circumstances? Does anyone have any advice?

Best case scenario is they count the whole thing as in network, worst case is they count half of it and hit me for $6000 total (both deductibles together)

I need to check, though, as there may be a maximum out of pocket coming into play also.

Thanks in advance

The_Jazz · 12-18-2008, 03:08 PM

Never done this nor seen it done, but I suggest that you call your state insurance commission, explain to them what happened and see if they can help you with the appeal. Generally speaking, they're one of the more pro-consumer agencies in any state.

mixedsubstance · 12-18-2008, 07:06 PM

I just wrote an appeals letter for Unemployment. Similar, I'd think. You need to state what it is you're appealing, the reason, and the main facts. Don't ellaborate too much or give it too much fluff and wording. Then, include your name, policy #, etc. and make sure you sign it. Make a copy for yourself. I guess you should also send copies of any proof and documentation you have. Look into it a bit more on the Insurance side to see what an appeal entails, etc.

telekinetic · 01-19-2009, 09:04 AM

Update to anyone who cares...I wrote a polite but insistent appeals letter (in Arizona there is a 3-tiered appeals process) arguing that these should be declared emergency services, and thus subject only to the associated $150 copay and no deductible (this was not clearly outlined in the materials I had from my employer, but I discovered it in my research).

This was in December, and I just now got a bill back from the hospital saying "XXXX paid by insurance, $150 remaining balance due" for the second event (the simpler one) so I'm hopeful that I might be able to get out of this mess for $300!

snowy · 01-19-2009, 09:16 AM

Quote:

Originally Posted by twistedmosaic

Update to anyone who cares...I wrote a polite but insistent appeals letter (in Arizona there is a 3-tiered appeals process) arguing that these should be declared emergency services, and thus subject only to the associated $150 copay and no deductible (this was not clearly outlined in the materials I had from my employer, but I discovered it in my research).

This was in December, and I just now got a bill back from the hospital saying "XXXX paid by insurance, $150 remaining balance due" for the second event (the simpler one) so I'm hopeful that I might be able to get out of this mess for $300!

Woo! That's good news.

dlish · 01-19-2009, 09:56 AM

dont assume we dont care TM. i just happened to read this thread first the first time just now.

thats great news. hope the recover has gone well.

i paid a shitload for my day surgey last year...my insurance company didnt cover anything but the general stuff. pissed me right off. couldnt even get cover if i wanted to!

i ended up telling my employer, that if they didnt help me out, id go back to australia to get free health care, and id have two months off at least. they obliged and paid 80% of the bill as a 'loan' and would write if off if i stayed more than 2 years with the company.

The_Jazz · 01-19-2009, 02:54 PM

Awesome. Glad to see the system worked for you!

12-17-2008, 08:45 PM	#1 (permalink)
telekinetic zomgomgomgomgomgomg Location: Fauxenix, Azerona	Need advice writing a Health Insurance appeal letter Background: I had sudden severe abdominal pain, so my wife drove me to the nearest hospital (accross the street), where they performed an emergency appendectomy. Three weeks later, I had stomach pain again in the same area, called my surgeon, and he advised I go to the ER as soon as possible for diagnostics. Total bills for both events = $40,000+ ($32,000+ and $8,000, respectively) The 'gotcha': My insurance (Humana POS) considers this hospital, and all of its services, 'out-of-network'. The difference in deductible between in and out of network is substantial ($1500 vs $4500). The footwork so far: I spoke with the billing agent at the hospital, she suggested I write an appeals letter to the insurance company requesting that, due to the emergency nature of the services, they be billed as in-network. I have copies of all my medical records to send in as well. The goal: Get all expenses covered under the in network deductible! The questions: Has anyone written a successful appeal letter for this or any other similar circumstances? Does anyone have any advice? Best case scenario is they count the whole thing as in network, worst case is they count half of it and hit me for $6000 total (both deductibles together) I need to check, though, as there may be a maximum out of pocket coming into play also. Thanks in advance __________________ twisted no more

12-18-2008, 03:08 PM	#2 (permalink)
The_Jazz Asshole Administrator Location: Chicago	Never done this nor seen it done, but I suggest that you call your state insurance commission, explain to them what happened and see if they can help you with the appeal. Generally speaking, they're one of the more pro-consumer agencies in any state. __________________ "They that can give up essential liberty to obtain a little temporary safety deserve neither liberty nor safety." - B. Franklin "There ought to be limits to freedom." - George W. Bush "We have met the enemy and he is us." - Pogo

12-18-2008, 07:06 PM	#3 (permalink)
mixedsubstance Crazy Location: Where the wild things are.	I just wrote an appeals letter for Unemployment. Similar, I'd think. You need to state what it is you're appealing, the reason, and the main facts. Don't ellaborate too much or give it too much fluff and wording. Then, include your name, policy #, etc. and make sure you sign it. Make a copy for yourself. I guess you should also send copies of any proof and documentation you have. Look into it a bit more on the Insurance side to see what an appeal entails, etc. __________________ Well, isn't that just kick-you-in-the-crotch, spit-on-your-neck fantastic?!? Without energy, there would be nothing.

01-19-2009, 09:04 AM	#4 (permalink)
telekinetic zomgomgomgomgomgomg Location: Fauxenix, Azerona	Update to anyone who cares...I wrote a polite but insistent appeals letter (in Arizona there is a 3-tiered appeals process) arguing that these should be declared emergency services, and thus subject only to the associated $150 copay and no deductible (this was not clearly outlined in the materials I had from my employer, but I discovered it in my research). This was in December, and I just now got a bill back from the hospital saying "XXXX paid by insurance, $150 remaining balance due" for the second event (the simpler one) so I'm hopeful that I might be able to get out of this mess for $300! __________________ twisted no more

01-19-2009, 09:56 AM	#6 (permalink)
dlish Currently sour but formerly Dlishs Super Moderator Location: Australia/UAE	dont assume we dont care TM. i just happened to read this thread first the first time just now. thats great news. hope the recover has gone well. i paid a shitload for my day surgey last year...my insurance company didnt cover anything but the general stuff. pissed me right off. couldnt even get cover if i wanted to! i ended up telling my employer, that if they didnt help me out, id go back to australia to get free health care, and id have two months off at least. they obliged and paid 80% of the bill as a 'loan' and would write if off if i stayed more than 2 years with the company. __________________ An injustice anywhere, is an injustice everywhere I always sign my facebook comments with ()()===========(}. Does that make me gay? - Filthy Last edited by dlish; 01-19-2009 at 09:59 AM.. Reason: Automerged Doublepost

01-19-2009, 02:54 PM	#7 (permalink)
The_Jazz Asshole Administrator Location: Chicago	Awesome. Glad to see the system worked for you! __________________ "They that can give up essential liberty to obtain a little temporary safety deserve neither liberty nor safety." - B. Franklin "There ought to be limits to freedom." - George W. Bush "We have met the enemy and he is us." - Pogo