Appealing a health insurance denial?
 

Arggh this has me so angry. My mom has breast cancer and her stupid insurance company denied coverage for her biopsy a couple of months agho because she didn't call them first even though she got the reference from her primary care nurse. So fine, she paid the $1000 for the biopsy with the knowledge that she better call the insurance company for every single thing to get pre-authorization. So last month she got surgery to remove the lump and some lymph nodes and that was covered fine, no denials showed up on the benefits summary for the surgeon, anesthesia, hospital, etc. Her surgeon assured her she was pre-approved for everything and when she called insurance a couple of days before the surgery to double check they gave her the green light.

A couple of days ago she got her benefits statement for the insurance and it said she was denied on the labwork to test her lymph nodes and margins for the cancer (thankfully the lymph nodes and margins were all clear and the tumor was less than 1cm, so it was about as good of news as we could get there). So she owes $1100 on that now to the lab that did it. She was assured by both the surgeon and insurance that everything was being done in network and the hospital is in network. I talked to the front office for the surgeon and they say she should be 100% covered, I talked to insurance and they said the hospital sent her tumor/margins/lymph nodes to an out of network lab.

What the hell? This is ridiculous, this insurance is pretty expensive and now my mom is getting hit with an $1100 extra charge after she did her due diligence with both the surgeon and insurance? Does anyone have any idea how to appeal this? The insurance paid the lab like $300 but the lab charged $1400. This is making me so angry that my mom pays through the nose for insurance and the moment she goes to collect on it she gets critical procedures denied.

I have no knowledge but wanted to say I'm sorry, it seems like they nickel and dime you to death except it's not just nickel and dimes anymore.
Our hospital takes a discounted price if paid in one lump sum or make monthly payments on the full amount.

I had somewhat of a similar experience when my dad got his endoscopy. Basically, the place my dad was getting his procedure done was in the process of "renewing" contract with anesthetist company(?). So the insurance company denied that part saying it wasn't covered at that time.

Anyone actually checks up on these type of things??? Anyway, I had to write letters few times and talk to few ppl but at the end of the day, it cover resolved.

Considering how much we pay for our premiums, it's ridiculous what we have to go through...

I am so sorry that your mom and you have to worry about frustrating insurance snafus on top of everything.

Here is a thread on reddit that has some info about appeals processes that might help you: https://www.reddit.com/r/personalfin...r_which_i_was/

My mom was treated for breast cancer in the 1980s, back when Blue Cross/Blue Shield took care of everything and insurance was a lot less complicated. Even then, we had one issue where they mistook a chemo drug as a wig because the name had the word 'plastic' in it. :rolleyes: They told us they didn't cover wigs and cosmetics. That was relatively easy to straighten out.

The insurance is doing an investigation into it now after I complained yesterday. Hopefully this gets resolved with it being fully covered as was promised by both surgeon and insurance.

You might think about asking the doctors/hospitals to,get the procedures/treatments pre-certified before,they do them. That way your might now get those awful surprises.

All insurances are different. But their bottom line is not - and unfortunately their bottom line does not seem to be their patient who is paying for the insurance.

So sorry your mom is going through this.

It's what she did. The surgeon told her everything was pre-approved by insurance and she discussed it with insurance before the surgery and they concurred.

After talking to the insurance company again today the insurance said she should not owe anything and that she should not get a bill. Thank God.