VAGOHandling Denials and Appeals
If your insurance claim is denied, review the reasons carefully, consult your policy for covered perils, and prepare for an appeal with additional documentation and expert opinions if necessary. 🚫🔄
vorlon@ProPublica But this story has a happy ending. The state appeal has been sustained and the insurance company has to cover it.
My wife was impressed; said that if it was her she wouldn't have bothered trying to appeal, assuming it wouldn't do any good and that a $3000 MRI was the cost of living under American healthcare. The hospital would almost certainly have written it down anyway, but people too often don't exercise their rights with insurance companies.
Scott JacksonJust got a call from #cigna (former colleagues at #Posit may want to pay attention) who said that there is a "new casemanager service at no cost to me" where they assign someone to ask me about my health.
Do not answer any questions.
This is a clear conflict of interest.
Insurance companies are not there to provide care for you, they're there to deny it. #ClaimDenied
賢進ジェンナ@ProPublica It's not #ClaimDenied, but I did have an issue with Cigna a year ago where they pretended not to have any covered psychologists/therapist in the area. After I called two or three other times and paid hundreds out of pocket, someone finally admitted that they gate-kept access to their list of supported mental health providers, requiring you to make the request several times before they'd acknowledge it.
Kevin Dalley@ProPublica
#Kaiser northern California has denied a simple claim of mine for 6 months.
#ClaimDenied
My wife purchased meds outside of Kaiser, because the price was a few hundred dollars a month less.
I submitted a reimbursement claim, but Kaiser screwed up, and put claim in my name rather than my wife's name.
Not a major claim, but nice to get reimbursed.
Since my wife hit deductible limit, this makes a difference in reimbursement.
For 6 months, Kaiser has promised to fix the problem, forcing me to jump through hoops.
Kaiser does not have a working grievance system, though required by state of California.
Case manager almost never returns phone calls.
I opened a few cases through
California Department of Managed Care (#DMHC).
Only slightly better than Kaiser.
DMHC returns phone calls only after multiple attempts.
DMHC closes cases without resolution.
DMHC does not share attempts at fixing systemic problems.
But after 6 months, I have another promise to fix the problem.
#Kaiser northern California has denied a simple claim of mine for 6 months.
#ClaimDenied
My wife purchased meds outside of Kaiser, because the price was a few hundred dollars a month less.
I submitted a reimbursement claim, but Kaiser screwed up, and put claim in my name rather than my wife's name.
Not a major claim, but nice to get reimbursed.
Since my wife hit deductible limit, this makes a difference in reimbursement.
For 6 months, Kaiser has promised to fix the problem, forcing me to jump through hoops.
Kaiser does not have a working grievance system, though required by state of California.
Case manager almost never returns phone calls.
I opened a few cases through
California Department of Managed Care (#DMHC).
Only slightly better than Kaiser.
DMHC returns phone calls only after multiple attempts.
DMHC closes cases without resolution.
DMHC does not share attempts at fixing systemic problems.
But after 6 months, I have another promise to fix the problem.
oldfartjmb says FREE PALESTINEMy durvalumab cancer therapy was denied a few months after it was started. It was to have been a two year therapy.
technicat@ProPublica #claimdenied I recently had an ophthalmology visit denied by Friday Health Plans because they terminated my coverage, which was news to me since they didn’t send me any notification of that. The cancellation was due to non payment of the premiums, which I didn’t pay because they haven’t been sending me the bills, either, and I assumed they were covered by ACA tax credits like they have been the last two years. However, they did send me the claim rejection, so I know the post office is still working.
Nathan SmithIn 2019, my wife had a stroke.
In 2020, she had brain surgery.
She was covered by different insurance companies for the post-stroke care, than for the surgery itself.
After fully recovering from the surgery, she was *still* getting pushback from the first insurance company about the hospital costs of the stroke.
This was well after the second company had already covered the cost of the surgery, which happened several months later.
soi6robertI had radiation my first bout with prostate cancer.
8 years later it came back. Doctors said surgery, but surgeon said no, can't be done.
Only option was HIFU, and I had to pay $25k out of pocket for a good off program doctor in Los Angeles.
My insurance didn't offer the treatment until 9 months later.
The urologists in Las Vegas, wouldn't touch me when I developed a blockage in my urethra. I had to return to L.A. for further treatment.
I applied for the $25k.
@ProPublica ok here's one
I am a metastatic cancer patient with a lesion on my liver that has been growing despite chemo. We consulted radiooncology to determine what interventions might be appropriate. There was concern that the lesion was too close to my small intestine to be safe to irradiate, because the intestine doesn't take radiation well. The doc wanted higher res imaging to be sure.
Claim was denied AFTER the MRI because MRI is not approved for tracking colon cancer.