How difficult is is to win a health insurance appeal? What is the best approach to take?

How difficult is is to win a health insurance appeal? What is the best approach to take?
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#1

My daughter is on my insurance. She has an ostomy. She was out for a hike in Seward, Alaska when her intestine prolapsed and she went to a local ER. They consulted with her doctor in Boston and as she needed emergency surgery and they did not have a surgeon in Sewrd they sent her to Anchorage via Med Flight. The bill is over 22,000 dollars for the flight of 127 miles. My insurance first said it was not medically necessary to go by plane and then after an appeal stated there was a closer hospital. Now Med Flight says we owe them the money. All other bills were paid, the surgery, the week long hospital stay etc…


#2

What a tough situation!

It sounds like you need some information and documentation from the "nearby" hospital that the insurance was insisting that your daughter should have used.  If they can document that there was no surgeon on staff that could have handled your daughter's case that should help with your appeal. 

Also, ask your daughter's doctor in Boston if he/she can provide documentation as to the timeline for the lifesaving surgery that your daughter needed.  Any professional journals or documents that the doctor can give you to support your cause that the emergency nature that caused the necessity of the air ambulance will also be helpful. 

Ambulance charge denials by insurance companies was a recent online discussion with the Alliance for Professional Healthcare Advocates.  Unfortunately, ambulance charge denials--no matter what type of transport---seem to be common.

Gather your documentation, then keep calling the insurance company to be sure that the right people are getting the right information in order to approve your air ambulance charges.  Also, stay in touch with the air ambulance company to let them appraised of your attempts to work to get this covered.  (You might also ask them, if you find a really nice helpful person with that company, what advice they might have to help your with your appeal.)

Good luck!  I hope you're successful!


#3

From experience, it is quite difficult to win a health insurance appeal, but that should not prevent you from appealing in a situation like this with so much at stake.

Also, you asked about the best approach to take.  I agree with the previous answer to try to resolve the matter by opening a strong line of communication with the insurance company. To be blunt though, you should file the appeal to get the process started now.  You may qualify for an "expedited" appeal given your circumstances.  Call and ask your insurance company about this.

Finally, if the result of the insurance company appeal does not satisfy you, then you should appeal to an external independent agency.  In Alaska, these appeals are handled by the Department of Health and Human Services (HHS.)  The information link to file that appeal is below: 

https://www.healthcare.gov/appeal-insurance-company-decision/external-review/

If your health insurance is not based out of Alaska, then appeal to the appropriate external review agency based on your State (also shown in the link.)

Hope this helps!



#4

Since you did NOT make the decision to fly her to Anchorage, you will need to get testimony from the referring hospital. Closer is only one of the issues. It may have been the severity of the situation and grave condition of your daughter far exceeded the capabilities of the hospital in closer proximity. Unless the health insurance company and the Med Flight company will cooperate, it will be up to you to find the answers when you make your appeal. It sounds like your best argument will be the capabilities of the closer hospital. Contact the Head of the Hospital where she was first treated and see if you can determine over the phone what went into the decision. It is likely that information was not in the documentation.

Hope this helps. It will be a tough battle because it is so far away.


#5

You received some great advice here! How did you make out?
I would also suggest asking about financial assistance on any balance that is remaining after your appeal.
If you need any assistance please reach out!
Cheryl Welch, MBA
Hudson Valley Medical Bill Advocates


#6

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