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You are here: Home / Anderson On Health Insurance / Stuck in the middle

Stuck in the middle

by David Anderson|  May 12, 201510:20 am| 27 Comments

This post is in: Anderson On Health Insurance

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A loyal reader raised the following question via e-mail:

what resources do you have when you are stuck in a fight between your provider and your insurer?

Medical tests were provided at the recommendation of a surgeon.  Insurer refuses to cover the tests.  Office of surgeon assures us that insurer should be covering at least part of the testing, and also office of surgeon has admitted that they know that insurer is problematic and has had issues with covering these tests.  I feel like we are being bullshitted by people on both sides and are stuck in the middle…..if tests were necessary why aren’t they covered, and it they aren’t covered and therefore of questionable necessity, why did the surgeon order them, and if the office of the surgeon knew the history of these tests being covered by this insurer was questionable, why did they not inform us of that fact?

The loyal reader is temporarily screwed as the provider and the payer/insurer are engaged in a pissing contest and the reader is in the middle without an umbrella.

There are a couple courses the reader can follow to get the tests paid for.  The most likely course of action is for the reader to appeal the denial directly to the insurer.  Insurers will deny for claims that they deem to be medically unnecessary.  The insured are not expected to be able to determine medical necessity as that is supposed to be a decision made by the doctor.  If there is ample documentation as to why this set of tests are medically appropriate, then the appeal will go through.

If this fails, it is time to escalate.  The patient should write a very nice letter to the insurer’s CEO, COO, and the director of complaints and grievances outlining why you believe you are getting screwed.  Politely note that this letter has been CC’ed to the major local newspapers and TV investigative or consumer protection reporters as well as the state attorney general and the state department of insurance.  Attach all relevant documentation and timeline as well as why you believe this should be paid.  The ask of the letter is a  request that the insurer honors its contract with you.

The reason why the insurance company ask letter works is that the insurance industry is slightly less popular than Ebola, so we’ll lose any public relations battle once it makes it onto TV or into the newspaper.

These letters do wonders.  Instant fire drills can be started to determine what exactly is happening, why it is happening, and whether or not we, the insurer screwed up.  A quick cost benefit analysis will often be performed to determine the cost of paying for the procedure even if the insurer is contractually not obligated to pay for it in order to make the problem go away.  A contra-indicated kidney transplant or Hep-C cure may fail that cost benefit analysis of paying without being obligated to pay, but “minor” problems under $10,000 will often be paid out to make a problem go away.

The next round of action is on the provider side.  If the insurer determines the test is still medically inappropriate, write a letter to the state medical board asking them to investigate why the provider is prescribing unnecessary procedures.   The medical director of the privilege providing hospital should also be CC’ed on this letter.   At this point, the provider may want to eat the costs of the test to make the problem go away.  You’ll probably need to find a new doctor after you try this.

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Reader Interactions

27Comments

  1. 1.

    lol

    May 12, 2015 at 10:26 am

    TPM has a great story about a Teatard who refused to buy health insurance because socialism, blew through all his savings when his shitty lifestyle choices came home to roost and now blames Fartbama because his state refused to expand Medicaid.

  2. 2.

    Roger Moore

    May 12, 2015 at 10:36 am

    The whole situation is ridiculous. If the insurance company wants to reject payment for tests and procedures, they ought to be required to vet them before the patient has already had them done, rather than having unlimited time after the fact to come up with excuses why they won’t pay. The whole system is based on a hopelessly broken design.

  3. 3.

    OzarkHillbilly

    May 12, 2015 at 10:38 am

    The loyal reader is temporarily screwed as the provider and the payer/insurer are engaged in a pissing contest and the reader is in the middle without an umbrella.

    Yep, currently dealing with a similar situation concerning a stomach scan. They are paying, but not what they should be.

  4. 4.

    japa21

    May 12, 2015 at 10:39 am

    The three most dreaded words to any insurance company is “Department of Insurance”.

  5. 5.

    Diana

    May 12, 2015 at 10:42 am

    I agree with the letter campaign. Back in pre-Obamacare days, I had a varicose vein that needed to be fixed. Oxford denied it, in the form of a decision suggesting that while I could appeal an initial denial, I was stuck if my request had received a second review, and suggesting – without being clear — that the denial I had received was a second review.

    So I wrote the second level review board a long letter explaining that I needed the vein in my leg to be fixed because I was a runner and unless it was fixed I couldn’t exercise (which happens to be true enough, but I figured it would convince them that it would be more cost-effective for them to pay now than to pay later) and they approved it and the vein got fixed.

    I never did find out whether my letter constituted my appeal to the second review or a reconsideration by the same people, but I did notice that the sneaky way they denied it would suggest to an ordinary person that they’d screwed up their own appeal.

    Go for the insurance company, but also make sure your surgeon is not fond of over-testing.

  6. 6.

    Iowa Old Lady

    May 12, 2015 at 10:42 am

    This happened to us once. Luckily, our insurance is through Mr IOL’s employer. We asked their HR department for help and they went to bat for us.

  7. 7.

    brendancalling

    May 12, 2015 at 10:43 am

    on an unrelated note, i haven’t paid my bill in 4 months. Can’t afford to. And, I’m tired of constantly making changes to my plan. I had to call up for a lower rate when I lost my job. Then I had to call back and get a higher rate when I got a new job (contract). then when the contract ended and I was out of work again, I had to call to get on Medicaid, but though the better of it when I got offered another short-term gig.

    I can’t do this anymore. It’s a time-consuming pain in my ass. My employment situation is ridiculosuly precarious and changes sometimes monthly. I don’t know what to do anymore.

  8. 8.

    rikyrah

    May 12, 2015 at 10:46 am

    thanks for the information

  9. 9.

    raven

    May 12, 2015 at 10:50 am

    So I sliced my pinky open. I held a towel on it while I bled and tried to locate a urgent care joint open on a Sunday evening without luck. I am about 100 yards from a hospital so I went to the ER. They patched me up and then saw a lesion on my forearm bone and said I should see the orthopod to rule out cancer. I specifically asked if I needed a referral and they said “no, we are referring you” and , indeed it was on the form. They tagged me $250 for the ER copay and off I went. Then I went to the oprthopod that is part of the hospital but says they are not part of the hospital and they said they had to have a referral from my GP so I called and they said they’d fax it. The ortho clinic then,with no copay, scheduled and MRI that turned into two mri’s and now I have an appointment with the surgeon tomorrow. The surgeons office called an told me to be sure to bring my motherfucking co-pay. Richard said it was a good idea to check my insurance info online so I did. The ER visit is not mentioned. The ortho visit is listed as denied but say I owe $0.00. I’m convinced the sawbones will want to do some further stuff to me to keep the “ruling out cancer” ball rolling and as long as it doesn’t keep me from fishing all week next week I guess I’ll play ball. Thanks for asking.

    Oh look, it does say this if you drill down: “- Additional information has been requested from the provider or the claim contains missing, invalid, or incomplete data needed for adjudication. You will receive a separate letter by mail requesting the specific documentations or questionnaires. This claim will be reopened for reconsideration once the requested information has been received.”

  10. 10.

    Bill

    May 12, 2015 at 10:50 am

    I had a situation like this once. It quickly became obvious that the insurer was the problem. Every time I called to resolve it, they would tell me the information could only be released to the provider. When the provider called, it could only be released to the patient.

    We fixed it by passing the phone back and fourth in the provider’s billing office. I’d authorize release to the provider, then she’d authorize release to me. We started off polite but by the time we were done, we were both screaming into the phone. When we finally finished the lady in the billing office hung up and said “What a bunch of f**king morons”!

    Somehow, they had mis-coded chest pains as an unauthorized cosmetic procedure.

  11. 11.

    Tim C.

    May 12, 2015 at 10:53 am

    @japa21:

    This. Unrelated to to medical insurance, but had a similar dispute over what kind of rental car we were entitled to after someone else hit our car and it was being repaired. Rental Car company provided one they said was an equivalent, Insurance company disagreed. 30 days into their dispute we got stuck with the whole bill. Got a stonewall from both sides when we called so the next step was the state regulator. That got us a very quick call back from the insurance company, a check for the entire amount and an apology for the “misunderstanding”

    Of course this is blue blue Oregon so your mileage may vary.

  12. 12.

    a hip hop artist from Idaho (fka Bella Q)

    May 12, 2015 at 10:59 am

    @raven: As long as you keep your priorities in order, and remember that fishing is next week. She reminds Sparky, enviously.*

    I’ll stop calling you that (eventually) but it just cracks me up to type it, so I’ll ask you to indulge me for a bit. kthxbai.xox

  13. 13.

    SenyorDave

    May 12, 2015 at 11:00 am

    I used to work in insurance, and although it was property and casualty, I will assume the same basic principal applies. Every state has a Department of Insurance in some form. If you really are in a battle with your insurance company, a call to the DOI is not a bad idea. Generally, they are pretty helpful, and trust me, no company wants official complaints from the DOI. At one company I was at, the complaints want directly to the president, and a SVP was in charge of making sure they were resolved. Bottom line, most companies take these complaints very seriously, and sometimes the threat of going to the Department of Insurance is not a bad bargaining tool.

  14. 14.

    terraformer

    May 12, 2015 at 11:01 am

    Medical insurance companies cannot go the way of Blockbuster soon enough.

    They do nothing other than take money from you, pocket a portion of it, and then give the rest to the actual medical provider.

    Their sole purpose is to deny coverage so that their portion is larger rather than smaller. Hell of a way to run a railroad.

  15. 15.

    piratedan

    May 12, 2015 at 11:03 am

    if you need additional guns, some states have a consumer watchdog arm over the insurance companies that you can lodge a complaint with, I know that Oregon does as I used them to lodge my complaint against MetLife when they denied my step-father’s Long Term care policy because they stated that because he could raise a fork from his plate to his mouth that this meant that he could feed himself. Never mind that he couldn’t drive, couldn’t shop, couldn’t prepare food and couldn’t clean up after himself….

  16. 16.

    MattF

    May 12, 2015 at 11:04 am

    I may be running into a ‘situation’ with my recently completed cataract surgery– I got an Explanation of Benefits form that denied payment to the surgery center (but not to the surgeon!) on the grounds that it was a duplicate claim. The second claim was three weeks later and for surgery on the second eye– so my suspicion is that there will soon be a little conversation between the surgery center and the insurer about the number of different eyes that were operated on. But we shall see.

  17. 17.

    japa21

    May 12, 2015 at 11:13 am

    One other point to make. Many contracts providers have with insurance companies deal very specifically with what the provider can charge the patient for and it is usually only co-pays and deductibles.

    Most have a clause that the patient can only be charged for a denied service if the patient approves in advance to have the service done knowing that it is denied. In a case where a physician is already aware that a particular payor has a history of denying payment for certain tests, it definitely is almost required they check with the insurance company prior to having those tests run and, if the provider then knows that they are unlikely to be covered to so inform the patient ahead of time.

    I actually put more blame on the provider in this particular case. I would suggest the loyal commenter involved here verify with the insurance company if the provider’s contract with them has such language.

    Of course, this is based on the assumption that the provider is in the company’s network. If not, all bets are off.

  18. 18.

    raven

    May 12, 2015 at 11:16 am

    @a hip hop artist from Idaho (fka Bella Q): No one ever called me that until ef got on my ass about some drive-b y douchebag started whining about full auto M-16s.

  19. 19.

    Roger Moore

    May 12, 2015 at 11:17 am

    @raven:
    I’ll say again that every time I hear about insurance companies, I’m more convinced that integrated payer/provider networks are the way to go. As a comparison to your experience, here’s my recent experience with Kaiser. I fainted at work with no obvious warning or symptoms, so when I came to, I was taken to Urgent Care. The Urgent Care physician had me get some blood tests to see if there was anything obviously wrong like an electrolyte imbalance, a head CT to check for any problems with my brain, and some basic tests for stroke. When those didn’t turn up anything, she referred me to cardiology and neurology to see if they could find any explanation for my symptoms. In neurology, I had a consult with the neurologist, who had me take two EEGs and a head MRI. She also filled out some paperwork to convince the DMV that I am safe to drive. In cardiology, I got an echocardiogram and a 30 day cardiac event monitor. When the echocardiogram showed possible signs of an enlarged aortic root, I got a consult with a cardiologist, who had me get another MRI. None of this turned up any evidence about why I had fainted, and the MRI contradicted the results from the echo that said I had an enlarged aortic root.

    The kicker, of course, is the payment side of things. I paid a $20 copay at Urgent Care, $30 copays for each consultation, and nothing for any of the tests. In a total of 9 trips, I paid $80 in copayments, filled out no paperwork (except for the DMV stuff), and had no arguments with anyone about referrals or billing. It’s just a vastly better way of doing things.

  20. 20.

    raven

    May 12, 2015 at 11:18 am

    @MattF: We went through that for over a year when my wife had some kind of prep for a root canal and then had the actual procedure a few days later. They kept saying that they wouldn’t pay for the same procedure on a tooth twice. They finally paid.

  21. 21.

    JCJ

    May 12, 2015 at 11:18 am

    If the doctor really feels the tests were indicated he/she should be willing to contact the insurance company. I have to call in to do these annoying “peer to peer” reviews to get approval on occasion. If I order a test that I know the insurance company will balk at I tell the patient that this will happen (often when ordering a PET scan.)

  22. 22.

    raven

    May 12, 2015 at 11:32 am

    @Roger Moore: They just started to offer Kaiser here, they have even built a new facility. In general I’ve been happy with BCBS, there seem to be these maddening problems if I look at the account but, if I let it go, they seem to pay in the end. They did go to $30 for the primary care doc and $50 for specialists.

  23. 23.

    shawn

    May 12, 2015 at 12:04 pm

    There are a lot of unknowns in the original question which makes it unanswerable, but the biggest variable is specifically why the claim was denied. A previous posted noted that providers have contracts with insurance companies and those specify what can and cannot be claimed by the provider. If the provider knew that they have “had issues with covering these tests” that tells me the doctor should know why they are having issues and how to avoid them if possible. The insurance company cannot move the goal posts on the member or the provider. Either way the provider should have done a benefits check with the insurance company before the services were rendered.

    I also wonder about what the patient means when they say “covered.” A lot of people hear the word “covered” and think it means “paid” when really all “covered” means is that it is eligible to be claimed against the member’s benefits. At least once I day a member asks me “If this is covered why didn’t you pay anything?” “Because it went to your deductible,” is the most common answer.

    Respectfully, a letter to the CEO will do probably nothing if it even gets to them. There are many levels of supervisor it would have to go through and if the member’s plan is clear that the service is truly not a covered benefit, or if the provider is truly not contracted to bill the service there is really nothing that can be done on the insurance company’s side. They stated at the time the policy was purchased what was and was not covered (same goes for when the contract with the provider was established) and as harsh as it sounds to blame the insurance company for sticking to that is not fair. Insurance companies do not give special treatment, especially after the fact.

    Again, without knowing what the variables are, giving advice on what to do is tricky. However the last piece of advice given was probably good – find another doctor if you can – it really sounds as if the business desk of that doctor is not doing as much as they can to protect their patients from unnecessary billing. I would also recommend to the patient that any time a doctor recommends a service or refers the member to a different doctor that the member call the insurance company to see what the coverage is for that service (the patient can ask for specific CPT codes – those are not secret) or if the new doctor is in network.

  24. 24.

    shawn

    May 12, 2015 at 12:06 pm

    the word member and patient in my post are interchangeable, sorry – i meant to use patient the entire time but habit had my typing the word member

  25. 25.

    SWMBO

    May 12, 2015 at 1:57 pm

    I have an autistic son that went through the “Command Voices” stage where he heard voices telling him to hurt someone. I was fighting with the insurance company to get him admitted (it took a neurologist, a psychiatrist and a psychologist to refer him for a hospital admission). I got the neurologist and psychiatrist to write up a referral no problem. The psychologist said his meds change could be done outpatient so no referral. I brought him into the psychologist’s office with a suitcase and a ziploc bag of meds. He told me (again) that it could be done outpatient. I threw the kid’s stuff on his desk and told him I wasn’t able to do it outpatient. I didn’t have the training or resources. Here is his stuff, call me when you get through it and I’ll pick him up. We got the referral.

    He was in the hospital once and they decided that they weren’t going to cover his bill because the inpatient psychiatrist wasn’t in their network. The hospital was but the doctor that treated him wasn’t in network. I took everything to the Insurance Commissioner’s Office with a word document that I edited every time I had called ANYONE about the bill. It went on for pages. I took all of it to the ICO and filled out a form. The guy I talked to (Mr. Booth) came out and said I had done the leg work for them (all that documentation) and they didn’t need to send out an investigator. He asked for a few minutes to make a few calls. After waiting over an hour, he came back out and told me that I shouldn’t have a problem after that. When I got home the phone was ringing and the insurance company wanted to know what it would take to make me happy. They kissed everything I stuck out after that. And they paid the bill. Later I was told that the ICO had told them that with the documentation that I had submitted, the insurance company could be fined $1000/day if it went to arbitration and they lost. They don’t want to hear that apparently.

  26. 26.

    Raven on the Hill

    May 13, 2015 at 12:15 am

    It’s nice that we can get insurance. It would be nice if the insurance companies showed some signs of actually being willing to honor their contracts. With individual insurance one has no HR department to go to bat for you when your insurance decides not to pay, so all you have is the state regulator, who may or may not be willing and able to help.

    Oh, and here’s another situation: try being injured by a friend’s pet. You get billed for care at the chargemaster rate.

  27. 27.

    Jing

    May 13, 2015 at 11:44 am

    @lol:
    Not a helpful comment. Just name calling. Thanks

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