Advice on filing an insurance appeal

[catrose]

My new doctor, as part of my yearly physical (paid for by insurance, remember?) ordered MRIs for my painful knee and back. Despite many, many calls to the insurance company (by the imaging place and me) BEFORE the MRIs, I now receive a letter from said insurance company saying they won't pay (which, of course, was the point of all the calls). If anyone has any advice on filing an appeal, please let me know.

[cbayer]

1. I think you should engage the imaging center and ask for them to do it.

It is that company that is making the charge and they have people that are super good at this kind of thing.

If they were not able to get approval and went ahead and did it anyway, I think the ball is in their court.

Unless, of course, they had you sign something saying that you were going to pay if it was not approved.

[antigop]

2. ok, here goes...I have filed appeals in the past

1) Did you read your policy? What does it say regarding MRIs?

2) If the policy says it should be covered, take the EXACT TEXT from the policy that states so. Reference the page number the text appears on.

3) Did you document each phone call? Did you get the customer rep's name? Do you have dates for those calls? Write them all down in your appeal. Do you know when your doctor's office called? Write that down. DOCUMENT EVERYTHING...every phone call....dates, times, conversations.

4) Make sure you follow the appeal process that is stated on your EOB and/or policy. Make sure you have the correct address.

5) When you mail your appeal, I would send it CERTIFIED mail and make someone sign for it.
That way you have proof the appeal was received.

6) Make sure you mail it in in time--see how many days you have to get the appeal on file. I believe my policy is 60 days...check what your timeframe is.

7) Find out what the procedure is if they still deny payment after your appeal.

Good luck....

[shenmue]

3. Best of luck

I have had this issue with some recent neurological visits.

[djean111]

4. Something just like that happened to my son, and his doctor's office folks took care of it.

No, they didn't pay it - whether insurance or Medicaid or Medicare pays for some things depends on whether the procedure is diagnostic, wellness checkup, or something like that. The doctor resubmitted the referral for the procedure with a different code, and then the bill was paid.

To illustrate, in Medicare, a yearly (or whatever) wellness-check colonoscopy is 100% covered. If the doctor finds polyps and cuts them out during the colonoscopy, the patient can get charged for that. Because the procedure went from wellness exam to diagnostic/treatment. As an aside, the colonoscopy guy gets paid more, of course, if he excises polyps and they are biopsied. At a place that the doctor owns. I had two "polyps" removed, and the nurse told me they were just pieces of colon, she did not know why they were snipped. I do. Did not have to pay anything. I have heard of people waking up from a colonoscopy with a big bill because polyps were found.

[catrose]

5. Thanks to all

I do have dates and so on, and the imaging place gave me a statement saying that they would accept whatever insurance paid, that I wouldn't be liable for anything…but I will call them tomorrow and ask how I can help get them some money. "Not medically necessary" after ten years of pain and attempted relief really chaps me, and being rejected after all the due diligence--well, you can imagine.

[cbayer]

6. Excellent approach!

Ask them how you might help them.

It's their problem not yours. That's your story and you're sticking to it.



Best of luck with your pain issues. It's a hell that can not be adequately described.