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A Galling Affair

Health insurers may automatically deny claims, but don’t let them get away with it

One thing I wasn’t prepared for after my emergency surgery two weeks ago was the increase in mail.

No, not get-well cards, although I did get a few of those and even more e-mails and phone calls. What surprised me was the barrage of mailings from my insurance company and its contractors denying my claims.

I’d gone to my doctor because of mild continuing pain and discomfort and because I had lost my appetite. She wanted me to have a CT scan right away, concerned that I might have appendicitis. Hours later I was in the emergency room, introducing myself to the surgeon and anesthesiologist who were ready to go when I walked in.

Fast forward (as you do when you’re unconscious), and I’m in the recovery room, thick tongued and not very articulate. They had removed my gall bladder, and the surgeon explained to me it was pretty bad and took twice as long as expected to get everything excised properly. Then it was ice chips and morphine, and my sister helping me settle into the hospital room. Generous soul, she had skipped a baseball game to give me a ride to the emergency room.

My daughter arrived the next morning, helping me through the three-day stay at the hospital and then at home. It seemed just minutes after I’d climbed into my own bed that I received the first “welcome home” denial-of-payment letter from my health insurer.

My initial reaction was anger, but I was pretty sure, based on my conversations with my health care providers, that they would put things right. Still, it felt like a body blow when I was already feeling beat up from the surgery. I could imagine someone else opening a similar denial and the damage it might do to recovery.

Reversal of denial

I have to say that the insurance company soon reversed its decision and allowed the payment for the surgery. And it reversed itself on the question of whether the CT scan had been medically necessary. I knew of the second decision because the lab called to tell me.

As a result, I wasn’t too upset when I received yet another letter, later that same day, from a company that had been asked to verify and authorize the services in question.

“Based upon this review, we regret that coverage for this service is denied for the following reason: We are unable to authorize the above procedure based on [the company’s] Abdomen Imaging Guidelines. The clinical information submitted does not describe the results of a recent ultrasound.”

The next day I received a second copy of exactly the same letter. Were the things being spit out by an out-of-control computer? Despite the absence of a gall bladder, I felt galled.

May I say that I have nothing against the idea of verifying claims and am an advocate of examining health care expenditures to make sure they are necessary. But that wasn’t what seemed to be going on here.

Instead, the companies appeared to be reflexively sending denial-of-payment letters with virtually no examination. I wondered, what was the point of sending what appeared to be mindlessly automatic denials of payment?

Some people just say OK

I called J. Robert Hunter, director of insurance for the Consumer Federation of America. The point, he said, is that some patients who receive those denial letters will just accept them.

“Some people just say, the insurance company must know, and back away. I think some of them tend to deny certain claims routinely, knowing that they’ll pay if the patient persists. They think maybe the patient will go away, and a certain percentage do.”

“Sometimes there is a reason why it was denied, and it’s legitimate,” said Hunter. Maybe you haven’t yet met your deductible or the treatment doesn’t meet the conditions covered in the contract, he said.

“But a lot of times it’s in a gray area,” he said. “Anytime a company is denying a claim or dragging it out, ask them to show you the language they are relying on.”

So, as painful as it may be, read all those letters. You should contest the denials and resubmit claims until you are satisfied. Like with me, the no may not really be a no.

Martha M. Hamilton writes a regular column for the AARP Bulletin on retirement and financial issues.

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