fighting with insurance company over denied claim - next step?

[Anonymous]

I threw out my back a few months ago. Dr ordered an MRI. When I got to the radiology center they told me insurance hadn’t approved it yet (they did not call to tell me, so I didnt know), and I could self-pay or go home and wait several weeks for another appointment. I was miserable and didn’t want to wait, so they had me sign a waiver releasing them from the responsibility of pursuing the insurance claim, but clearly told me I could submit it myself.

I’ve now submitted it 4 times. The insurance company has thrown out every reason under the sun that they wont pay - it wasn’t approved (my dr called their peer reviewer and I have an approval notice and number); that I didn’t submit the right paperwork (I resubmitted the same docs and highlighted relevant information); that I signed away my right to pursue the claim (I have a copy of the waiver and I am a lawyer - I did no such thing, I only released the radiology clinic from the obligation to pursue); and now that it’s out of network (also clearly not true).

I’m ready to take legal action - any advice on the next step? Are there lawyers or non-profits that do this? Should I threaten to take them to small claims court?

The honest truth is I can afford the $500 I paid, but I’m outraged enough at this treatment to be willing to invest some time in getting my money back, because they are so obviously in the wrong.

[Anonymous]

With insurance I paid like $350. Just eat it, it's not worth your time.

[Anonymous]

Have you appealed the denials and/or escalated the denials to exhaustion? I've found that it takes hours of phone calls and/or written submissions (from me and the dr.) to reverse a decision. I'm also a lawyer and I've had to fight tooth and nail for certain medication for my DD to be covered--and I have to go through this process every year (the medication is approved for a one-year period). Every year, they insist my DD try up to 3 different medications to "prove" she needed the one at issue even though her doctor submitted all the info explaining why this medication was unique, the reasons she needed that one, and despite the fact that she's been on it and it's working for her. After repeated calling and escalating it to managers and other senior team members--explaining that I cannot put my 10 year old on a drug trial to satisfy their random criteria when her own doctor prescribed it and it's working--I am able to get an "exception" and the medication gets approved. Although I'm fortunate enough that I can find the time to deal with all of this, it's sickening that anyone should have to go through all of this to get medical care.

My situation is different than yours but I share it in case it proves helpful to you. Every insurance plan is different and the procedures are different, but if you have the time to continue to fight, go for it. Given the amount at issue, I'm not sure retaining an attorney to pursue this makes sense (you'll pay more in legal fees than your out-of-pocket costs) but you could certainly pursue if you feel strongly about it (although I have no recs, sorry). GOOD LUCK!!!

[Anonymous]

With my policy you always need approval before the MRI takes place. would be surprised if any policy did not require that, but I assume you’ve checked. I agree 500 is not worth it. Always get MRI approval first.

[Anonymous]

Call your local congresspersons office

[Anonymous]

Insurance commissioner in your state

[Anonymous]

You might be out of luck. The MRI almost certainly required prior authorization. That would/should be ignored in an emergency situation, but this doesn't sound like an emergency.

You say you have an approval notice. If that really is an approval notice, then the state insurance regulator/consumer protection agency might help you. But I'm guessing that wasn't really an approval, but notice that approval was sought. Similarly, the doctor may have needed to do a peer-to-peer as part of the prior authorization process, but that doesn't mean the full process completed.

[Anonymous]

Anonymous wrote:With insurance I paid like $350. Just eat it, it's not worth your time.

UHC has entered the chat.

[Anonymous]

I think we should all make it cost insurance companies more to deny claims for physician-ordered tests than it is to just pay them.

Call. Take up staff time — electronic communications won’t get it done. But always, always be nice to the people on the front lines. They aren’t the problem.

Make sure you know the diagnostic codes and billing codes when you call. I make my insurance calls while driving or doing housework or making dinner, to ensure that it doesn’t actually cost me valuable time.

[Anonymous]

Anonymous wrote:You might be out of luck. The MRI almost certainly required prior authorization. That would/should be ignored in an emergency situation, but this doesn't sound like an emergency.

You say you have an approval notice. If that really is an approval notice, then the state insurance regulator/consumer protection agency might help you. But I'm guessing that wasn't really an approval, but notice that approval was sought. Similarly, the doctor may have needed to do a peer-to-peer as part of the prior authorization process, but that doesn't mean the full process completed.

+1

[Anonymous]

Anonymous wrote:You might be out of luck. The MRI almost certainly required prior authorization. That would/should be ignored in an emergency situation, but this doesn't sound like an emergency.

You say you have an approval notice. If that really is an approval notice, then the state insurance regulator/consumer protection agency might help you. But I'm guessing that wasn't really an approval, but notice that approval was sought. Similarly, the doctor may have needed to do a peer-to-peer as part of the prior authorization process, but that doesn't mean the full process completed.

In addition, your plan may require that the provider bill if they are in network so signing away that obligation may also bar your claim.

There are places that pursue this sort of thing but not for a $500 MRI bill. Also, you could have tried to get an earlier appointment elsewhere for your MRI once you got the approval. You likely would not have had a long wait.

As someone who has been handling medical billing issues for decades, I can tell you that I have never seen an insurer or third party administrator pay for an MRI without prior approval.

[Anonymous]

Pay the bill that you signed off on saying you would pay the bill!!!!

You get to wait like the rest of us for pre-approval you're not special.

[Anonymous]

Anonymous wrote:I think we should all make it cost insurance companies more to deny claims for physician-ordered tests than it is to just pay them.

Call. Take up staff time — electronic communications won’t get it done. But always, always be nice to the people on the front lines. They aren’t the problem.

Make sure you know the diagnostic codes and billing codes when you call. I make my insurance calls while driving or doing housework or making dinner, to ensure that it doesn’t actually cost me valuable time.

It sounds like it wasn't denied. Rather, the OP didn't bother to wait until prior authorization was obtained.

[Anonymous]

Anonymous wrote:

Anonymous wrote:With insurance I paid like $350. Just eat it, it's not worth your time.

UHC has entered the chat.

Nope, I have CareFirst

[Anonymous]

Anonymous wrote:

Anonymous wrote:With insurance I paid like $350. Just eat it, it's not worth your time.

UHC has entered the chat.

DP, but $500 out of pocket, depending on your plan, is not unheard of. I was quoted $800 out of pocket for an MRI at a hospital.