Overturning Insurance Denials: A Cautionary Tale

Its great to win a hard one. One of the things I do is to file appeals for people who have been denied payment by their managed care company. As Paul Krugman recently wrote about in the NY Times, a good portion of the costs of health care is spent by insurers paying the small army of administrative denial managers. Too often someone will call me after they have made their first appeal and blown their timely filing guidelines clearly stated in the fine print of every insurance contract. Once the 45 days are over (a typical time limit), if the patient hasn’t responded, they lose. That medical bill is theirs.

My case was a woman who went over seas and got pneumonia. Trying to do the right thing, she immediately called her insurance company with information that she had been hospitalized.

The denial came before she even got home: lack of medical necessity. All inpatient admissions are subject to concurrent review. Since my client was overseas in a way-out-of-network hospital, the insurer lacked any way to coordinate care.

One big problem was that when I got the case it was over a year old – timely it wasn’t. But I was able to find a clause in the contract where I could press the case, so I sent it out for external appeal to the Insurance Commissioner. You would think this office is there to protect consumers: not so. They, too, made a finding about lack of timely filing. See, the clock started ticking from the moment medical records were received. Apparently a phone call from a different continent was enough of a medical record for the IC’s office to blow us off.

But I had also sent the same appeal back to the original insurer, who called to ask, “What medical records?” I had attached 11 pages of medical records to these appeals, which were mysteriously removed before the appeal got out of the mailroom. Only the careful wording of my letter made the examiner call and asked me to fax the documents directly to her. And, we lucked out with the examiner, too. He gave us a fighting chance.

Voila! We won!

External Appeal? Don’t count on it. Unless you can demonstrate real malfeasance, I’m afraid your case won’t get a fair shake.

Cross-posted at http://trusted.md/columns/medical_bill_advisor