AboutTricia Expertise Has your medical insurance company denied your claim and refuses to pay? Have
you received a pre-authorization and still your insurance company
refuses to pay? How can you get your insurance company to reverse a
denied claim? How do you get a provider to waive your copayment if you
are financially unable to pay? What are fee schedules and are you
responsible to pay them? Can a provider sue you for a unpaid bill and
will they? Can a provider send me to a collection agency for a medical bill?
If my insurance company does not pay, am I responsible?
If you have these questions or others on why your insurance company is
not paying your bills, I can help. I can give you "tricks of the trade"
to get your insurance company to pay.
Experience In the medical field for over 18 years spending majority of time in the collections aspect.
Question Hi, I am in Florida and looking for a strategy or guidance on appealing my HMO pre-authorization denial. I am a prostate cancer patient. I went out-of-network because my in-network doctors, 1)could not provide cure/success rates of their treatment, and 2)did not provide the same treatment (similar, but the same) my current clinic provides. My efforts in attempting to obtain cure/success rates are well documented. My current clinic's cure rate is well documented. The denial was based soley on the fact I went out-of-network. I appealed and currently are waiting for a date. I'm looking for suggestions on presenting my appeal. Thank you for any assistance you can give. Craig Leveen.
Answer Hi Craig!
When submitting an appeal to over ride a denial, you need as much "medical" proof as you can to stand by your decision.....so I would recommend any third party information be presented.......perhaps your DR can write a letter of necessity and state why they would give better care than other DR's......maybe articles about their success rate, etc. Find out from your employer if anyone else has gotten a denial overturned due to your same reason...sometimes this helps to say you know that they have paid a claim before under these same circumstances...they can not play favorites so this may help.
In an appeal, you must have so much information from others that your HMO can not say no.......bombard them with anything and everything you can..... the more you have to back up your claims, you will have a better chance of winning.
You may also get your employer involved.....sometimes they can get denials overturned.......since they pay the premiums, insurance carriers seem to listen to them a bit more than the patient.
Stick to the medical necessity for the reason of your choice and don't give up......appeal twice if you have to......plus perhaps get your attorney general or insurance commissioner involved if you must.......
Insurance companies like to beat you down.......don't let them.......fight until you have no recourse.....I know for a fact that at work I got many denied claims over turned just because the patient and our company harassed them until they paid.
