Well, my insurance company changed our preferred provider to a different hospital. My CF doctor, however, wouldn't treat me at the other hospital. Being that my lung function was down from (May) 80% to (Oct) 36%, I felt it was crucial to be treated by my doctor whoknows me and my history andis listed asthe only CF clinic in AK on the CFF, then to be treatedby any old pulmonologist. My insurance company disagreed. They are billing me for close to $50,000 for making the choice to be treated by a non-preferred hospital. Normally, they would pay 80%, but this time they only paid 60% and apparently, still billed me when I went over the yearly max I was supposed to pay. I want to appeal it, but I'm not sure what to write to convince my insurance company that they should pay the normal 80%. Has anyone had a similar situation or have some advice for me? Thanks in advance.
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appeal
- Thread starter Jeana
- Start date
I had a similar situation a few years back, except I chose to go to the hospital that my insurance covered. I know what needs to be done well enough to guide a regular pulmonologist and my CF team was willing to consult with him. I made it through just fine and didn't have to worry about the insurance not paying. About the only thing you can do at this point is see if the hospital is willing to work with you as far as financial assistance and perhaps a payment plan.
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drdanika
Guest
I would talk to the financial counseling office at the hospital you were at. If they can't write anything off as charity, they may be able to help you with the appeal.
Best of luck!
Best of luck!
Hi Jeana,
I have been following your posts and about your recent tribulations health-wise and I'm soo sorry that you now have to deal with this on top of everything else! Insurance and financial issues are so stressful! Ugh.
I know that Julie on this site is now helping people with insurance appeals in addition to SSDI claims. I have heard that she has been quite successful with insurance appeals so far. I'm sure she would be willing to help you or at least help you get started. You could PM her on here or go to her foundation's website www.dafcf.org. Julie helped me with my SSDI claim and I was approved within about a month of my first application. Sorry if you have already contacted her and this is redundant! You could also call the CF legal hotline/Beth Suffian, however, I have heard she is already out of grant money for all of 2012 and can't take any new cases. I have only heard that through the grapevine however, so don't take my word on that.
It sounds like you should definitely be able to get some sort of override to see your doc, considering he is the only CF doc in AK at an accredited center. Good grief!!
Otherwise as a last resort I would second what the previous poster's have stated and contact the hospital regarding financial assistance. Gosh though, even with financial assistance with that amount you could still end up owing an arm and a leg! That's pretty astronomical! I'm sorry!!
Good luck and keep us posted!
Autumn
I have been following your posts and about your recent tribulations health-wise and I'm soo sorry that you now have to deal with this on top of everything else! Insurance and financial issues are so stressful! Ugh.
I know that Julie on this site is now helping people with insurance appeals in addition to SSDI claims. I have heard that she has been quite successful with insurance appeals so far. I'm sure she would be willing to help you or at least help you get started. You could PM her on here or go to her foundation's website www.dafcf.org. Julie helped me with my SSDI claim and I was approved within about a month of my first application. Sorry if you have already contacted her and this is redundant! You could also call the CF legal hotline/Beth Suffian, however, I have heard she is already out of grant money for all of 2012 and can't take any new cases. I have only heard that through the grapevine however, so don't take my word on that.
It sounds like you should definitely be able to get some sort of override to see your doc, considering he is the only CF doc in AK at an accredited center. Good grief!!
Otherwise as a last resort I would second what the previous poster's have stated and contact the hospital regarding financial assistance. Gosh though, even with financial assistance with that amount you could still end up owing an arm and a leg! That's pretty astronomical! I'm sorry!!
Good luck and keep us posted!
Autumn
Even if she switched companies right now, it wouldn't help that she still has 50 K plus in hospital bills that have already been incurred....but, if the option exists for future hospitalizations, it would be worth looking into. For the time being, get the financial adviser from the hospital on board, see if there are any programs that you might qualify for. I know that my local hospital has a foundation that helps those who are underinsured or have high bills and low income despite insurance. From what I understand, many hospitals have some version of this kind of help. Excellent idea to get Julie on board too, she has helped so many, I know that she could help you too. Also, try the social worker in your clinic, they might be able to find help as well. I hope that this gets resolved, it sucks that good care is so expensive and that insurance companies dictate where we can go. I had to go out of network once, racked up a huge bill but in the end, the hospital wrote a good part of it off so I as lucky in that aspect..Good luck to you, I know that this is very stressful. Jenn 40 w/CF
Hi Jeana!
I had this issue when I moved to Toledo and the only CF clinic was in a hospital network not covered with my insurance. Because it was the only accredited CF center within a certain radius, they had to cover my trips to the doctor, hospitalization, and labs/xrays associated with my CF care. I had to appeal every claim for a year and basically wrote that it was the only accredited CF center and I needed to have tests/hospitalizations done where my CF doctors practiced. Everything was overturned and they covered it. After a while, I was able to get a letter put in my file stating to approve certain things without me having to keep appealing them. Did you talk to someone in your insurance and explain the accredited CF center issue and talk to a supervisor. Until I did that everything was always denied. Let me know if you have any questions and I'd be happy to try and help!
Erin
I had this issue when I moved to Toledo and the only CF clinic was in a hospital network not covered with my insurance. Because it was the only accredited CF center within a certain radius, they had to cover my trips to the doctor, hospitalization, and labs/xrays associated with my CF care. I had to appeal every claim for a year and basically wrote that it was the only accredited CF center and I needed to have tests/hospitalizations done where my CF doctors practiced. Everything was overturned and they covered it. After a while, I was able to get a letter put in my file stating to approve certain things without me having to keep appealing them. Did you talk to someone in your insurance and explain the accredited CF center issue and talk to a supervisor. Until I did that everything was always denied. Let me know if you have any questions and I'd be happy to try and help!
Erin
Have you requested a retroactive out of network authorization yet? If not, I'd go that route first while simultaneously appealing their decision. My initial reaction is to tell you that you are likely screwed, however, if there is a loophole, my organization can usually find it. If you would like to send me a copy of your denial (please remove all identifying info at this time) and also a copy (or online link) to your benefits booklet, I would be happy to take a look at it. services@dafcf.org
<div class="FTQUOTE"><begin quote><i>Originally posted by: <b>Printer</b></i> Given that you are being billed $50,000 plus your monthly premiums, you can afford to change insurance companies. Remember, you can no longer be refused for PRE-EXISTING CONDITIONS. Bill</end quote>
Bill, I believe pre-existing conditions can still be denied until 2014. That is according to <a href="http://www.healthcare.gov/law/timeline/full.html">http://www.healthcare.gov/law/timeline/full.html</a>.
To Jeana, you mentioned that you were billed over the yearly max. This is typically referred to as the out of pocket maximum. Usually insurance will have two such figures: one for in-network, and one for out of network (the out of network is usually higher). There is no way they can get away with not covering the amount you owe that is in excess of the out of pocket max, so at the very least, your appeal should achieve that. E.g. if your out of pocket max is $10,000, the insurance must cover the remaining $40,000.
In addition to the other resources suggested, your state may have a Customer Assistance Program that can help you with your appeal. Check <a href="http://www.healthcare.gov/using-insurance/managing/consumer-help/index.html">http://www.healthcare.gov/using-insurance/managing/consumer-help/index.html</a> to see if your state has one. I've never dealt with them, so I don't know how useful they are.
Good luck! I've battled insurance companies before, and it's not fun.
~Gordon
Bill, I believe pre-existing conditions can still be denied until 2014. That is according to <a href="http://www.healthcare.gov/law/timeline/full.html">http://www.healthcare.gov/law/timeline/full.html</a>.
To Jeana, you mentioned that you were billed over the yearly max. This is typically referred to as the out of pocket maximum. Usually insurance will have two such figures: one for in-network, and one for out of network (the out of network is usually higher). There is no way they can get away with not covering the amount you owe that is in excess of the out of pocket max, so at the very least, your appeal should achieve that. E.g. if your out of pocket max is $10,000, the insurance must cover the remaining $40,000.
In addition to the other resources suggested, your state may have a Customer Assistance Program that can help you with your appeal. Check <a href="http://www.healthcare.gov/using-insurance/managing/consumer-help/index.html">http://www.healthcare.gov/using-insurance/managing/consumer-help/index.html</a> to see if your state has one. I've never dealt with them, so I don't know how useful they are.
Good luck! I've battled insurance companies before, and it's not fun.
~Gordon
D
DrRoe
Guest
Jeana, I think you have a good case for appealing your insurance company's ruling as (I believe) the standard of care is through a cystic fibrosis clinic. So first I would appeal directly to your insurance company, and if they don't respond the way you want, then I would file a complaint with your state's health insurance agency. Each state has an agency that regulates health insurance plans. Some are more proactive than others and can simply overrule an insurer, while others only make recommendations. I'm not sure which state you are in, but this map has links to each state's health insurance agencies http://www.naic.org/state_web_map.htm Roe =====
First of all, thank you for all of your responses. I just heard that the hospital approved my request for financial assistance, which lowered my bill to $10,000 instead of $50,000. However, that stills leaves a $500/mon payment and that doesn't include my other medical costs (prescrips, labs, xrays, other hospital payments and physicians). To that end, I am still trying to appeal. I am going through each of your suggestions and will be trying everything. If any of you have a letter of appeal that you have written as a starting point for me (without indentifying info) please PM me. Thanks again!
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BikerEd
Guest
That will not solve her problem now.and frankly will not solve her problem in the future. I personally would like to have one place NOT to argue politics, I can assure you the last place I want the government involved is my healthcare. Been there; done that, got the T-shirt NOT going back.
MsPeliAmour
New member
I'm curious...I'm assuming your doctor couldn't treat you or see you in that particular hospital because he wasn't affiliated with it. That's normal. However, you stated your doctor "wouldn't treat me at the other hospital." Did he refuse to participate in your care altogether (by communicating with another doctor that might be assigned to you at that hospital)? I ask because I may have just started seeing your doctor (if it's a CF doctor in Alaska) and that's bothersome to me that he'd rather have you have financial hardship (which can affect your health) than make the extra effort to communicate with another doctor so you could be treated at your in-network hospital. Also what do you plan to do in the future when you need to be admitted? Will you keep going to your doctor's affiliated hospital?