How do I appeal a medical bill denial?

How do I appeal a medical bill denial?
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#1

I had a colonoscopy/endoscopy in my GI doctor’s office who is in my plan and I was told by his staff that everything was approved by my insurance. But I received a bill for around $1000 from an out of network anesthesiologist (apparently though, Humana has no in network mobile anesthesiologists) and told I have to pay whole amount since out of network. I have already paid my deductible too. I was told by Humana with a prior colonoscopy that having it done in a doctor’s office is cheaper for them.


#2

This happens all the time, and can be very frustrating to deal with.  My suggestion is to:

Call the Customer Service number on the back of your insurance card and ask for an explanation of why the claim was denied or Why wasn't the claim paid for out-of network provider rates.

At this point, you most likely will be talking to an "entry level" customer service person. Be kind, they have a computer screen in front of them and they can only provide the information that is available to them.  Escalate up to supervisor or manager, if you don’t receive an adequate answer.  ALWAYS ask for the name of the person you are talking to before you hang up. Some insurance companies will provide a record of conversation I.D number; write it down so you can refer to it later.

2. If the insurer tells you that it is not their error but instead something your doctor or hospital can correct, your next step is to call your provider. Ask them to review the claim again, tell them what you know from the insurance company, and request they resubmit a corrected claim.

3. Here's where it can get tricky. If the denial is neither an accounting or administrative error, but was denied because the treatment for which reimbursement is being requested is not covered by this provider," you will need a different approach. Do your research on coverage policies first, and consider all the appeal requirements for your insurance company.(Be sure to follow the timeliness guidelines too)  If the region you reside in does not have in-network providers for this specialty find out the usual and customary rates for this service type and region, and request that reimbursement be made according to UCR. 

Then file an appeal using the information that best support the use or appropriateness for the care/treatment you received with this provider. Enlist the assistance of your primary healthcare provider, as well as any other care/ treatment records relevant to your appeal.  If that doesn't work you may want to consider enlisting the assistance of a patient advocate.

Good luck

Lisa Homan



#3

As a billing manager for anesthesiologists for over a decade, I can tell you that the anesthesiology fees are legitimate and payable, even if no service was directly rendered. As long as the anesthesiologist is in the room, his time and expertise while monitoring the procedure are due. This is called MAC anesthesia.

You have a recourse to force Humana to pay the bill in full:

Call Customer Service/Claims, explain that you want the claim reprocessed as:

1. you did not have a choice of an anesthesiologist

2. services were medically necessary as they were ordered by the surgeon

3. None of the anesthesiologists at that facility are contracted (if one is not, none is as they work and bill as a group)

4. the facility services were rendered at is in network.

5. you are being billed for the full balance.

Humana should ask you to submit as copy of the statement, and should reprocess
the charges for full payment. They will likely not ask you to file a
written appeal but if you have to, the above 5 points should get the
charge reprocessed. I have used these arguments for years to get
additional payments.

Make sure you send in a copy of the statement, and
notify the anesthesiologist’s office that an appeal is under way to keep
your account current and avoid collection action.

If the
appeal were denied, turn to your state’s insurance commissioner’s office
and file a grievance as Humana would be in violation of a couple federal
and state statutes.

Best of luck,



#4

We see this often and sorry you have to deal with this.
There is a lot of overcharging for routine colonoscopies and patient’s not being made aware of anesthesia services and that’s because routine colonoscopies include conscious sedation and are not separately billable.
If this was not considered a routine colonoscopy then the anesthesiologist can bill for the service but it should be billed as in-network rate as long as the surgeon doing the procedure was in-network.
Hope this helps!
Cheryl Welch, MBA
Hudson Valley Medical Bill Advocates


#5

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