Maybe OT: Any advise on writing an appeal to insurance?

[jbn3boys]

I have to file an appeal to my insurance company to try to get a specific doctor covered as an "in network provider". This doctor was pad the first time I saw him. The second time, it was considered "out of network" an I am responsible for 100% of the bill.

I'm just wondering if anyone here has any advise on writing letters of appeal to insurance companies. I want to make sure I get this right. This is a doctor which was recommended to me, which I like, and whom I hope to continue to see. Any help would be greatly appreciated!

[JohnBFisher]

Though I do not have any specific recommendations, you can certainly find example letters if you use the following search terms:

medical insurance appeal letter sample

Hope that helps.

[Emilia]

Has the doctor's office verified he is no longer considered in network? If his office/manager can verify this, there must be a reason for dropping him and they would know it. If they are unaware of being dropped, it may be an error on the part of whomever handled your last claim. I think, before you write a letter, you need to ascertain the full situation from every angle to be sure your facts are correct.

EDIT: As an example, my sleep doc's office submitted my post study visit to my insurance for reimbursement, and it was denied. Turned out it was just a coding error. Once it was resubmitted with the right code, it was covered.

[LSAT]

The doctor may have dropped the insurance company. When a doctor is 'in network' he agrees to a reduced payment. The payment from this particular insurance company may be so low that the doctor felt he could no longer accept the low 'in network'
payments.It may be the doctor and not the insurance company you should be speaking to.

[jbn3boys]

I did talk to the insurance company, and they claim the first visit was paid "in error". Since the error was on their part, they will not re-bill me for it. However, they say the doctor is not in network. I have since checked on the insurance website, and for the specific type of doctor I am seeing, there are only 4 listed in my area, none of which are affiliated with my clinic group. I think the insurance company has dropped the clinic group for this specialty.

[Emilia]

If that is the case, I doubt you will be able to do much. Certainly, you can ask your doctor's office why they continued to take your insurance info if they knew they were no longer affiliated with your company.... and it seems unprofessional of them to not advise you that they were not part of that coverage. Seems there was a lot of miscommunication on the part of the doctor's office and the insurance company.

You should check out the 4 doctors on the list and choose to go to one of them.... otherwise, you are stuck paying the additional out of network costs.

[Wulfman...]

I did talk to the insurance company, and they claim the first visit was paid "in error". Since the error was on their part, they will not re-bill me for it. However, they say the doctor is not in network. I have since checked on the insurance website, and for the specific type of doctor I am seeing, there are only 4 listed in my area, none of which are affiliated with my clinic group. I think the insurance company has dropped the clinic group for this specialty.

What did they say they pay on "out-of-network" medical providers?
They typically pay SOMETHING.........usually from 50% to 80%.

I found out that my (high-deductible) retiree coverage pays 85% for in-network doctors and 80% for out-of-network doctors.


Den

[chunkyfrog]

Dont you just hate it when you have to change doctors?
Especially when the old one was good.
I hope there is a good 'un in the 4 you can pick from.

[Emilia]

The OP said she was responsible for 100%..... some insurances, usually HMO's, will not cover out of network at all on some things.

[cowlypso]

Your only hope might be to argue that, since they paid the first visit, you thought that the provider was in-network, and continued to see them, so they should also pay the second visit. However, I don't think there's any way that you will get them to cover anything beyond that. Now that you know the provider is out of network, if you choose to continue seeing him then you are responsible for the charges.

And even with that argument, I'm not sure you'll get anywhere. If the insurance website does not list that provider as in-network, then you were responsible for knowing that and seeking out an in-network provider. Sadly, it is not the doctor's nor the insurance company's responsibility to know your coverage.

Perhap ask for the insurance to pay some percentage, if they won't cover the whole visit? Call the doctor's office and ask for a discount?

[jbn3boys]

Your only hope might be to argue that, since they paid the first visit, you thought that the provider was in-network, and continued to see them, so they should also pay the second visit.

Exactly. This is what I am doing.

I was originally doing this all over the phone, and was told by the insurance company that there was a good chance that an appeal would allow me to continue to see this specialist. However, I got a call this morning telling me that since this was issued in my state (and not a neighboring state, where I assume this portion of this insurance company is based), I will have to do my appeal in writing.

To answer the out of network payments....I am responsible for 100% up until my (high) deductible--a separate deductible than my in-network deductible. With the amount of times I expect to see this specialist, I do not expect to meet that out of network deductible, so I will be 100% responsible.

And as far as those other 4 doctors who ARE in network--one is no longer taking new patients, and one I have been told "see anyone BUT him". So I'm really down to only two. In an area the size I live in, that is just unacceptable to only have two doctors.

[Janknitz]

It's worth an appeal, to get that visit covered, you have about a 50:50 chance. Meanwhile, you should ask the doctor personally if he will give you some sort of cash discount for paying out of pocket for his services. Some doctors will do this, particularly if they don't have to bill your insurance company themselves, as this costs time and money. If you really like this doctor and can afford to pay an agreed-upon reduced rate, it may be worth sticking with this doctor. Most doctors are willing to work with you, so it's worth asking.

You can submit the bills to the insurer yourself for reimbursement (that you won't get), simply for the purpose of counting against your deductible, in case something else crops up that contributes to meeting the deductible.

The other option is to find a specialist who does take your insurance within driving distance--not necessarily in your immediate area. I find I have to be willing to drive to places within a 2 or 3 hour radius to get some of the specialty care needed. It's worth it--I've been able to access a cardiologist who specializes in adults with congenital heart disorders for myself (it's very hard to find these doctors!) and various pediatric specialists for my daughter who aren't available locally with our HMO (Kaiser) but are in the Kaiser system if we travel to them. If you keep track of the medical miles and dollars spent you may be able to deduct them from your taxes.

[jbn3boys]

I seriously checked the insurance website LAST week, and there were four physicians for this specialty. I just checked today, and there are TWO! One who is not taking patients, and one whom I was told "See anyone BUT him".

[leejgbt]

I can help you with this. I have been in this industry for 26 years as well as being an insurance agent for seven years. There are several questions you will need to answer first:
1. Were you referred to this physician by your personal physician?
2. What insurance company is this?
3. What type of coverage? Is it a trust? An HMO?
4. Where is the nearest in network provider? Would going to this provider cause a hardship?

Give me as much information as possible and I will let you know if an appeal will work. If an appeal is warranted I will then help you write it.

[codinqueen]

I have UHC Choice, considered an EPO plan (kind of like a picky PPO), and they cover ONLY in-network costs. If I go out of network for medical care, I am paying it 100% BY MYSelf! MAKE SURE BEFORE USING ANY PROVIDERS THAT THEY ARE CONSIDERED IN-NETWORK to get the most bang for your insurance premium buck.
I am pretty skilled at writing appeal letters, used to write them routinely at the Dr office where i was employed as a coder, but you are kind-of an "odd-one-out". Did you verify that the Dr you saw was an "in-network provider" BEFORE you visited him the first time? If you were told he was, do you have the date and time, and name of the person you spoke to at the insurance company telling you he was IN-network? You could send the EOB showing that they paid the first time around and explain that since the first visit was paid as in-network, your hope is that they should cover the 2nd visit, since you were not aware the Dr was no-longer In-network. Most insured people do not check the provider list for in-network providers before EACH and EVERY Dr. visit, and it is unfair of your insurance company to expect you to do that, after THEY are the ones who processed the first claim erroneously, leading you to believe he was IN-network, due to THEIR error. ALso, I think you will need to change to one of their IN-Network providers for future care, unless you can convince the insurance company that your continuity of medical care will suffer, and therefore your health may decline, if you are not permitted to continue medical treatment with the same Dr. Worst they can do is say "no" as to paying as in-network care, and continuing to cover this Dr for you as an IN-network provider, by special arrangement. If you get a special arrangement from the insurance co to allow you to continue to see this DR, get the agreement in WRITING, print it, and keep it for future problems if any arise. Good luck!