I had pre-approved surgery and was subsequently denied a claim from my insurance for being out-of-network. I've appealed twice and been rejected. What do I do now?

I had pre-approved surgery and was subsequently denied a claim from my insurance for being out-of-network. I've appealed twice and been rejected. What do I do now?
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#1

Nearly one year ago I fractured my hand snowboarding. I had to have surgery and prior to surgery I was informed by several people at my Doctor’s office and at the surgery center that I had received approval from my insurance company (Cigna). After surgery Cigna denied my claim and only covered 25% of my medical bill. Cigna’s reason for denial was that my surgery was done out of network. I have appealed Cigna twice and have been denied twice. My appeal options have been exhausted and I am now stuck with a bill that is greater than 17,000. I am wondering how i should proceed from here? Do I get a patient advocate? Hire a lawyer? I am not sure what to do. Any help or advice would be much appreciated.

Thank you,

Andrew


#2

I hope that you have healed since your accident.

Approval for payment does not equate to full payment of a claim.  Approval of a procedure means that your insurance carrier agreed with the provider that the services requested met your insurance plans requirements and were medically necessary.  Your claim was still fully subject to your Out Of Network benefits.  Appeals are for when the claim did not process correctly or there was an error in the initial billing.  If your previous appeals were only in regards to the allowable amount by your insurance carrier, then it would not have qualified for further action.  What you can do is the following:

  • Did your Out Of Network provider agree to accept the allowable amount as payment in full?  Call your insurance carrier and ask them if your provider 'Agreed to Accept Assignment', another way to ask the same question is to ask if Box 27 was checked as Yes or No.  If your this provider agreed to accept assignment, then they are telling the insurance company that they would accept the allowable amount as payment in full.  
  • If the Out Of Network provider reported 'No' in box 27, then you can still contact them and begin negotiation of your bill.  When contacting the provider's office a quick tip, as someone regularly takes these calls, make the your billing department contact person your new best friend and ally.  When speaking with first request for the whole amount be discounted in some way.  I suggest going to a health care pricing site like www.healthcarebluebook.com.  You can use these sites like this to get an idea of what is fair for your area, these amounts are not written in stone.  
  • Your next option is to request to make payments on your bill.  

Good luck!


#3

It is regrettable that you have already used all your appeal options.

You may have more options available to you, including filing a grievance with your state's department of insurance, but what truly matters is the wording on the actual authorization letter.

Does it say anywhere that services were to be paid at the "out of network" rate? If yes, you cannot win any appeal or grievance unless you can prove that the services were rendered in a life or limb-threatening situation. 


If there is nothing indicating the level of reimbursement, you should then turn to the facility for an explanation as to why you were not informed prior to surgery that the facility was not contracted with your plan. Although it is ultimately the patient's responsibility to check whether a provider is in network, it could be considered that the facility did not act in good faith by not notifying you.

In some states, medical providers are legally mandated to give you this information and provide you with a written estimate of the cost.In this is the case, I might advise you to file a complaint with either the Compliance Dept or the Patient Relations Dept. This failure on their part could lead to a reduced bill.

Another option is to get screened for financial assistance. Hospitals have private or federal-subsidized programs you may qualify for. Call the business office and ask for an application, or check the website for criteria.

If all else fails, negotiating a settlement is your next step. Ask the insurance if they can give you an in network fee estimate (or use the "cost estimation" tool on the website using a contracted nearby facility). If you offer to pay the full agreed-upon balance now rather than over a number of months, you should be able to wrangle an additional discount.

Best of luck!


#4

Hello, Andrew.

This question is definitely beyond the scope of my financial planning skillset.  However, my first instinct would be that you might indeed do well to present your situation to a patient advocacy firm.  Such consultants are likely better suited to deal with the complexities of insurance claims issues than you are on your own and are likely to be less costly and more expeditious than an attorney.  At the very least, a patient advocacy firm may be able to give you a better sense of the strength of your position and whether or not it is wise or necessary to enlist an attorney. 

Patient advocacy is a rapidly growing segment of the financial planning profession.  If you are not familiar with any firms that offer such services, you may wish to contact Crown Care LLC.  Crown Care is a Hawaii-based company that provides patient advocacy and health insurance navigation services.  I have no affiliation with Crown Care, but believe that their service offerings fill a valuable planning niche.

Good luck.

Aloha,
JR



#5

wow!
So Cigna did not deny it but paid 25% reduced rate for out of network.
This should have been appealed because this was emergency surgery? They would have had to give authorization for the surgery and should have paid at the in-network.
If your internal appeal options are no longer available you can do an external appeal.
I would highly suggest obtaining a medical bill advocate who can audit the medical records for errors in coding, compliance and pricing and/or negotiate your out of pocket expenses.
If you still need assistance please reach out.
Cheryl Welch, MBA
Hudson Valley Medical Bill Advocates


#6

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