Disputing Insurance Claims & Payouts
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Disputing Insurance Claims & Payouts
Does anyone know if it's possible to get a health insurance provider to change their
mind about covering something if you can make a good case? My 5-year-old son
has had severe social problems (aggression, hyperactivity, explosiveness, extreme
sensitivity) which has turned his life and ours upside down. After 18 months of
research and endless attempts to evaluate and treat, we discovered he has
significant vision impairments and is improving at a dramatic rate as a result of
vision therapy. As was the case with a majority of the treatment avenues we've tried,
our insurance doesn't cover vision therapy. We attend weekly appointments which
cost about $500 a month and will likely continue for the better part of a year I
imagine (we started 2 months ago). We're tapped out financially from all our other
treatments and if I thought there was a way to appeal to my insurance company
(United Healthcare), it would be well worth the time and energy of going through the
appeal process. Is that even possible or is it an open and shut case with what they
Someone told me if I could get letters from professionals that have been involved
with his care (teachers, occupational therapists, his pediatrician, etc) that could
express his need for help, his vision impairments, and his progress thus far, that
they might appeal. Do they ever change their minds? If I were to build a case, who
would be the best people to get letters from? What would the letters need to say to
get their attention? Who would I send the letters to?
If anyone has any experience with this I would love to hear about it, even if it's to
say that I shouldn't bother. Thanks alot!
You didn't mention in your post if your child is seeing an OT
right now, but an OT may be able to administer some of the
vision therapy. My son was tested by the binocular vision
clinic at Cal and in their report they recommended a series of
exercises which were carried out by his OT at school.
Hi, the therapy we offer at the sensory learning center has
vision therapy as one element. The question of insurance
coverage comes up quite frequently. United has paid in the past,
but it does seem that arguing your case well makes a difference.
What works for our patients is:
a) A referral from a licensed health care practitioner.
b) A procedure code for the therapy
c) Tax id for the therapy center
d) date of birth for the patient
e) health coverage # for the patient
f) diagnosis code for the patient (usually a part of the
Even with all these in place, there is sometimes resistance.
Persistance does pay off.
I'm not exactly sure what his Vision Therapy consists of, but
my daughter required multiple Opthalmologist visits because one
eye was much weaker than the other. She had to be checked at
least every several months, and for awhile once a month. She
wore a patch on her strong eye to try to force the weak one to
improve (it did, significantly.)
These visits were billed as medical rather than vision services
and were fully covered by our health insurance at the time
(Aetna). Our vision coverage provided for only one visit per
If your son's issues are behavioral rather than medical you may
be out of luck. However, if there is a medical component to
the behavior problems you may be able to come at it from that
I would love some advice from anyone who knows how to go about
appealing services denied by an HMO (Health Net) for
(alternative) health therapies. Has anyone had any experience
with this? Health Net has approved services for the western/
allopathic care (pediatrician, neurologist, prescriptions
(which has very little to offer for my teenage
daughter's ''transformed migraine'' and chronic fatigue syndrome)
and deny the things that have actually brought releif
(acupuncture, osteopathic manipulation, etc.) I would be
grateful for any recommendations, names of professionals who
could help, similar experiences, etc. Kris
I understand your frustration. But unfortunately, if it's not written in your
policy, then the insurance company doesn't have to pay and the likelihood of
getting them to pay is close to none. Double-check your policy. If they
cover procedures that are like these, then you may want to ask your doctors /
actupunctursit, etc. to amend the writing of the treatment in your claim. I
don't mean lie. But sometimes insurance companies will only cover something
that's stated with specific language and procedure. You can have had that
treatment, but the insurance company won't pay because of how the claim is
written. But essentially if the insurance company doesn't cover these
procedures, you may want to look for another provider who does.
I have Blue Cross/Blue Shield PPO medical insurance. Under the
terms of my plan, I have minimal costs associated with medical
procedures so long as I use a ''preferred provider.'' In addition,
I am not responsible for the difference between the billed
amount and the allowed amount negotiated by my insurance company
so long as I use a ''preferred'' provider. Last May, my daughter
had ear tubes placed in her ears. We selected to ''preferred''
surgeon and a ''preferred'' hospital (Children's Hospital Oakland)
Unbeknownst to me, the hospital outsourced the anesthesia for my
daughter's procedure to a ''non-preferred'' anesthesiologist - who
then promptly sent me a bill for $540. My insurance company
sent me a check for $150 which was 90% of their allowed amount
for a ''non-preferred'' provider and says that I am responsible
for the difference. Needless to say, I'm outraged. I did
everything I could to maximize my insurance benefit but now I am
required to pay almost $400 for anesthesia - which by the way is
more than double what I had to pay for the entire surgery. I
have already appealed and lost the benefits determination with
my insurance company. Does anyone have any advice on what I can
do about this or am I just stuck? Thanks.
There is a department of insurance in California. I don't know
if it will oversees your medical insurance, but it might.
They are there to help you get treated fairly by the insurance
companies, and complaints to them go on the insurance company
official records. You should get useful help if your problem
falls under their auspices, they just helped us out after a 4 month
nightmare of arguing with our insurers and feeling powerless to get
them to do their job.
Boy do I know what you are going through. I had a similar situation with the birth of
my second child. It turned out that the pediatrician who happened to be on to
check my baby when she first came out was ''out of network'' despite the fact that
the hospital is in network. My friend had a similar situation when she went to the
emergency room at a network hospital and the doctor who happened to treat her
wasn't ''in network.'' I don't know what insurance companies expect you to do in
these situations. Was I supposed to stop the doctor from checking my newborn and
before I had even delivered the placenta get on the phone and talk to some
insurance company bureaucrat to check her credentials? In my case, eventually the
insurance company paid, but it took a long fight, with the help of my HR person at
work, and in the end they acted like they were making a special exception for me in
allowing me to do something not allowed by the policy. My only advice is to not
accept it and keep fighting it until they give in, but I would love to hear if anyone
else has any advice about changing this ridiculous situation overall.
Fed up with health insurance companies
If Blue Cross/Blue Shield has already determined you a
responsible it is probably just an expensive lesson in just how
uch homework you have to do when dealing with a PPO. At a
fraction of the cost I also learned the hard way with
my 'PREFFERED'' provider who did lab work for me and sent it out
to a non-preffered lab. At length I discussed the situation with
my preferred provider facililty who in the end didn't cover an
of the cost for me but did ask more questions about insurance
before making assumptions. Unless you are willing to ''go all the
way'' and get a lawyer etc. involoved I am not sure that you have
much choice, I would certainly talk to Children's Hospital and
make sure they are aware.
The Medical Board of Calfornia offers services to consumers that
deal with quality of care to dishonesty issues. This group has
made things happen for both me and my wife. I believe that the
insurance company's front line people are often told to deny
claims, coverage, or complaints as many consumers just drop
their issues then. Check them out, and then follow through. It
can be a lengthy process but worth going through the exercise.
We have this exact same problem right now. In August, we landed
in the Children's Hospital ER with our one-month baby who, as it
turned out, had pyloric stenosis. He was very dehydrated because
of all the vomiting (it will take me years to get over the guilt
of not taking him in sooner, but I thought he was just spitting
up alot, ugh). He is totally fine now. Everything was covered
as ''in network'' in our Blue Shield PPO plan. Just this weekend,
however, I got a bill for over $1300 from the anesthesiologist.
Apparently, although the hospital, the surgeon, the ER doctors,
the primary care doctors, etc., were all part of the PPO plan,
the anesthesia group is not ''contracted'' with Blue Shield. Of
course, we had absolutely no way of knowing this, and no one ever
said anything to us about choosing our own anesthesiologist. In
fact, we had absolutely no benefits counseling whatsoever. So, I
called Children's Hospital today, and eventually spoke to an ''in
patient'' representative who was somewhat helpful. She told me
that because our baby was admitted through the ER, the insurance
should pay the claim at an ''In network'' rate. This is apparently
because we had no way of knowing anything about or choosing our
own doctor (duh). She told me to dispute the claims processing
with the insurance company, and that they might pay more. I am
not sure how this will turn out. I suspect an unfair business
practice by someone (the anesthesiologists? the hospital? the
insurance company? not sure, but consumers are the ones getting
screwed). If you want to email me directly about this issue,
If you filed a grievance with your health plan and got nowhere,
try filing a complaint with the Department of Managed Health
Care at www.dmhc.ca.gov.
--Sounds shifty to me
I actually had almost exactly the same thing happen to me a few
years ago. I had to have surgery for a broken ankle. I have Blue
Cross and I researched a Blue Cross hospital (Alta Bates), a
Blue Cross surgeon, then the hospital used a non-Blue Cross
anesthesiologist who insisted that I pay the difference b/w what
Blue Cross paid him and what his actual fee was, which was
several hundred dollars.
Anyway, I was outraged as well, especially since the insurance
company agreed with me that I had no choice over the
anesthesiologist chosen. After numerous outraged phone calls I
finally ended up talking to a woman at Alta Bates who was
familiar with this situation and who told me to call Blue Cross
and ask for some kind of special exception based on the
circumstances....she gave me a catch phrase to use which
unfortunately I can't remember exactly....which allowed them to
treat the doctor as if he was a blue cross doctor. Anyway, I
promptly called back and used the phrase with Blue Cross only to
be told that they didn't use that kind of exception in CA (can't
remember why). To which I of course said that my Blue Cross
hospital just told me that you could. Then they finally caved
and said OK and paid the anesthesiologist.
Anyway, what to recommend? Perhaps call Alta Bates and try to
get the exact wording of what you sould tell the insurance
company? Sorry I'm a little vague on the details, but the upshot
is, I didn't have to pay the anesthesiologist bill.
Been there with Blue Cross
Although I'm sure there are some pieces of info missing in
your story this is what I can tell you. First, Childrens
hospital does not outsource any of it's anesthesia services.
The anesthesia is 100% pediatric anesthesiologists who are part
of the Childrens Anesthesia Medical Group. All members of the
group are part and parcel to the contracts with the insurer, in
this case blue cross/shield. You need the insurer to tell you
first of all whether or not they have a contract with the CAMG
medical group (the anesthesiology group). The answer should be
yes. Then ask them why the particular member of the group who
did your childs anesthesia is not considered a preferred
provider. I suspect they will review this and see they made an
error. Sometimes the lower level agents at an insurer will pass
on some erroneous piece of information such as the ''outsourcing
statement in order to explain a billing mistake.
At the very least you should contact the appropriate government
agency or agencies regulating your PPO. I don't know who that is,
but the CA Dept. of Insurance and the CA Dept. of Consumer
Affairs would be two good places to start. If that fails, call
your assembly member or state senator. Sometimes merely the
threat of regulatory action is enough to convince a business to
treat you fairly.
We had the EXACT same thing happen with Children's Hospital.
And, my son had an emergency appendectomy - like we had a
choice on the anesthesiologist! I battled with Blue Shield and
they did pay at the higher rate, minus my deductible. It wasn't
great, but better than what you got. Get your insurance broker
involved. Their intervention I've found works wonders. Keep
being persistent. Last resort, negotiate a reduced fee (what
the insurance would have paid) with the anesthesiologist. I'm
so sorry this happened to you.
got the insurances blues...
I also have been caught in this billing catch 22 between my
health care plan and the Anesthesiology group at Children's
Hospital. It sadden's me to read about all the others who were
caught when they were at thier most vulnerable with a sick child.
You can(with preserverance)get your health plan to acknowledge
that you did not have a choice of anesthesiologist and they will
pay out at the preferred rate. That does not obligate the
Anesthesiology group (other than ethical obligations perhaps) to
accept that as payment. And they won't. Why should they? They
have a monopoly on the service and you are just one person. You
can check your provider. You can check your hospital. That just
leaves everyone else. How many folks get caught in this predatory
business practice? The CEO of Children's Hospital is Tony Papp.
The e-mail address of the head of the Hospital charitable
foundation is Mpetrini@mail.cho.org. The email address of the
head of the anesthesiology group is email@example.com. Hope
I was surprised to learn that so many people have been going through the same
thing! My son has been treated at childrens hospital Oakland now and he needs to
have surgical procedures quite often. We have a health insurance (United
Healthcare), and I am dealing with exactly the same thing. While Childrens Hospital,
my son's oncologist, and lab work are in network, my anastegia fee and fee from
sergical center (clinic?) are out of network. What I have learnt by talking with
insurance company is that they have an exception called SAP (Surgery, Anastegia,
and I forgot what P stands for). If SAP was performed with in-network doctors at
the hospital (or ER) which is also in-network, SAP is also considered in-network and
should be covered as in-network. It is because my son had no choice but to go with
those anastegists who are out of network, because they work in the same in
network facility (in this case, Childrens Hospital Oakland) with in-network doctors.
Maybe you can ask your insurance company to see if they have this SAP exception
policy. My son's case has not yet been resolved, and I may have to move on to
request an audit (they processed our claims as out of network first, and I am
requesting them to handle those claims as in-network) but that is supposed to be a
policy (and my right to receive coverage).
this page was last updated: Apr 19, 2010
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