Monday, February 19, 2007

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



Anonymous Anonymous said...

Facts that are believed to exist regarding the present U.S. Health Care System-
This may be why about 80 percent of U.S. citizens want our health care system overhauled:
The U.S. is ranked number 42 related to life expectancy and infant mortality, which is rather low.
U.S. is ranked number one in the world for spending the most for health care- as well as being number one for those with chronic diseases. About 125 million people have such diseases. This is about 70 percent of the Medicare budget that is spent treating these terrible illnesses. Health Care cost presently is over 2 trillion dollars of our gross domestic product. One third of that amount is nothing more than administrative toxic waste that does not involve the restoration of the health of others. This illustrates how absurd the U.S. Health Care System is presently. Nearly 7000 dollars is spent on every citizen for health care every year, and that, too, is more than anyone else in the world.
We have around 50 million citizens without any health insurance, which causes about 20 thousand deaths per year. This includes millions of children without health care, which is added to the planned or implemented cuts in the government SCHIP program for children that covers about 7 million kids.
Our children
Nearly half of the states in the U.S. are planning on or have made cuts to Medicaid, which covers about 60 million people, and those on Medicaid are in need of this coverage largely due to unemployment. With these Medicaid cuts, over a million people will lose their health care coverage and benefits.
About 70 percent of citizens have some form of health insurance, and the premiums for their insurance have increased nearly 90 percent in the past 8 years. About 45 percent of health care is provided by our government- which is predicted to experience a severe financial crisis in the near future with some government health care programs, it has been reported. Most doctors want a single payer health care system, which would save about 400 billion dollars a year- about 20 percent less than what we are paying now. The American College of Physicians, second in size only to the American Medical Association, supports a single payer health care system. The AMA, historically opposed to a single payer health care system, has close to half of its members in favor of this system. Less than a third of all physicians are members of the AMA.
Our health care we offer citizens is sort of a hybrid of a national and private health care system that has obviously mutated to a degree that is incapable of being fully functional due to perhaps copious amounts and levels of individual and legal entities.
Half of all patients do not receive proper treatment to restore their health, it has been stated. Medical errors desperately need to be reduced as well, it has been reported. It is estimated that we need about 60 thousand more primary care physicians to satisfy the medical needs of the public health in the United States. And we have some greedy corporations that take advantage of our health care system. Over a billion dollars was recovered for medicare and Medicaid fraud last year through settlements paid to the department of Justice because some organizations ripped off taxpayers. These are the taxpayers in the U.S. who have a fragmented health care system with substantial components and different levels of government- composed of several legal entities and individuals, which has resulted in medical anarchy.
Thanks to various corporations infecting our Health Care System in the United States, the following variables sum up the U.S. Health Care System, which is why the United States National Health Insurance Act (H.R. 676) is the best solution to meet our health care needs as citizens. We would finally have, as with most other countries, a Universal Health Care system that will allow free choice of doctors and hospitals. It should be and likely will be funded by a combination of payroll taxes and general tax revenue:
Access- citizens do not have the right or ability to make use of this system as we should.
Efficiency- this system strives on creating much waste and expense as it possibly can.
Quality- the standard of excellence we deserve as citizens with our health care is missing in action.
Sustainability- We as citizens cannot continue to keep our health care system in existence , or tolerate it as it exists today any longer,
Dan Abshear

10:11 AM  
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