My insurance-biller-SIL once advised me when they wouldn't pay up (even though they previously assured us we were covered for the services we needed-midwife) to send them a certified letter (with the bill) stating that if they don't pay within the month that we would be reporting them to the insurance commission (or whatever the gov't insurance agency is called). She said that they are required by law to pay within a month. This is in Oregon, BTW.

3 denied claims
The liver biopsy that diagnosed my cancer 7 years ago (Doc said cured!) because it wasn't pre-approved. Of course it wasn't. The doc doing my upper GI endoscopy ordered a STAT biopsy - I was barely out of the anesthetic for that when I was had the biopsy.
I appealed and failed.

Installing my med-port - it was pre-approved, but some insurance co. clerk coded the procedure wrong.
I appealed and I'm pretty sure that the insurance company paid it (I had a few other things on my mind...).

Blood Transfusion after my last chemo treatment - it was done as an outpatient procedure in the hospital's ambulatory clinic. The word "clinic" was why the claim was bounced. The insurance company told me to have the hospital re-bill it and remove the word clinic, and then they'd pay it. The hospital didn't.
Fail.
What REALLY bit about that one was that it was a directed donation from my mother. Not at all relevant to the billing issue, but definitely the crowning cherry on the whole pile of s---.

Our son was scheduled to have open heart surgery in March. The day before the surgery, during the presurgical testing and lab work, they decided that, due to a rash that he had on his chest, they couldn't perform the surgery. The cardiologist billed the tests as a consultation instead of a presurgical consultation and the tests were not covered. What a load of BS.

How to appeal denied coverage...
Be less of a liability.

@HIV 2 Elway:

Sure, just don't get sick, and if you are unfortunate enough to get seriously or chronically ill, just go off somewhere and die to help contribute to Aetna CEO's second yacht payment.

FOAD, please.

@Archteryx: Hard to have any sympathy when a smoker or alcoholic gets denied coverage. Not sure if you realized this, insurance companies are in business to make money, not lose it.

former insurance csr....be nice ... and ask the rep for "their help", we usually got $250 we could play around with each claim, not so much when the customer outright asked for the claim to be paid, go figure.

@HIV 2 Elway: Sadly, this is true. Insurance companies nowadays are making profits by selling expensive insurance to people who least need insurance. It's become a huge scam, on everyone. People who need to use their insurance can't get their company to pay out, and people who don't get overcharged to pay for massive corporate profits.

@HIV 2 Elway: Those people are a vast minority of the people being denied claims.

@HIV 2 Elway: Also, getting sick is not a moral failing. Stop viewing it that way.

@HIV 2 Elway: "Not sure if you realized this, insurance companies are in business to make money, not lose it."

Not sure if you realized this, but there's no guarantee that an insurance company will actually make money. And if a given insurance company's business plan relies on denying coverage in order to make their nut, then perhaps that company deserves to go out of business.

@johnva: No, but being unemployed is. It's not hard for any educated person to find employment that provides insurance.

@johnva: My insurance costs me less than $600 a year, granted some of that is subsidized by my employer. I guess that's one of the perks of taking control of ones life, educating yourself and find ample employment.

@BigElectricCat: Minimizing risk has to be a part of their business plan.

I once had a procedure done by an in-network doctor at an in-network hospital that got rejected by my insurance company because they claimed it was out of network.

It took a lot of angry phone calls and letters between me, the insurance company, and the hospital, but after six months, the insurance company paid up.

I'm actually apposed to health insurance being a profit making enterprise. Property insurance, ok make a profit (if you can with hurricanes, tornados and the like) but not for health care.

@johnva: I agree: Getting sick is not a moral failing, but making money of someones misery is.

@HIV 2 Elway: The complaint isn't people don't get denied coverage - people get denied benefits.

Your screen name, HIV2, hmmn. Should people who contract HIV through unsafe sex be denied benefits, because they should have known better, like smokers and alcoholics?

Yes insurance companies need to make money. They also need to fufill their contractual obligations to customers that they have provided coverage for. So what exactly is your point?

@HIV 2 Elway:

Your naivete is refreshing!

@HIV 2 Elway: What's your point? Don't get sick or don't get insurance?

The point here is that the insurance companies, while working well within their rights to minimize their risks and maximize their profits, are twisting their system to deny claims.

How to appeal denied coverage...
Untwist the system.

@miran: I agree with you. This sort of behavior is the natural end result of for-profit insurance. They have a direct economic incentive to pay as little in claims in possible. For-profit insurance doesn't work well for healthcare. I don't blame the profit-hungry companies so much as I blame our government for failing to regulate or outlaw their industry.

I'm getting really tired of people implying that if someone doesn't have the good healthcare coverage they do that they must not have worked as hard, or been a smoker, alcoholic, etc. The worse your health is, the harder it is to get affordable coverage (sometimes, it's hard to even get a job then because employers don't want the cost of a chronically ill person). And many serious health conditions are just the result of bad luck.

@SkokieGuy: I wouldn't want to underwrite someone with the hi five.

@SkokieGuy: Just reread the post, didn't realize we were dealing with people who had procedures performed only to have coverage denied. That is bogus. I was referring to people applying for new insurance coverage and being denied. If someone is an obvious liability, no insurer should have to insure them.

Then you are not endorsing insurance companies who provide coverage, then deny benefits. You simply suggest that insurance companies should refuse to insure people who are sick, or have a high potential of becoming sick. How Charming.

And to others, it's not just insurance, our entire healthcare model, drugs, hospitals, doctors and insurance being for-profit is logical, ethically and morally wrong. It obviously pits the profits against the amount of care provided.

This is also why natural treatments (herbs, minerals, lifestyle changes like meditation, massage and accupuncture) are not well investigated, reported or supported, because these are not patentable ideas that would lead to a monopoly on sales and profits.

@HIV 2 Elway: "If someone is an obvious liability"? Who should insure them then (especially if it's something detectable but not their fault, like a genetic disease)? The government? If you allow private insurance but dump the "high risk" people on the government, what you're doing is privatizing the profits of healthcare and socializing the costs. Why should the taxpayers have to pay for people who have genetic diseases and such just so that private insurers can make a profit on healthier people? Isn't that an indirect subsidy of private insurers from the government? Or are you suggesting that anyone with any preexisting condition should just be allowed to die (regardless of whether it's their fault)?

@SkokieGuy: I was with you until your last paragraph. "Natural" treatments like you mentioned ARE well investigated. And in many cases derivatives of them CAN be patented...for example, plants have been a huge source of new compounds for pharmaceuticals. And there is still a market for pharmaceuticals and such that isn't a monopoly situation...after all, there are generic drug makers.

The real reason these things aren't used more often here in the U.S. is that many of them do not work or have not been proven to work. I have no desire to throw my money at something that there is no evidence will help, and insurers likewise do not pay for treatments for which there is no evidence of medical necessity.

@SkokieGuy: Yet what country attracts the most doctors and provides the most medical breakthroughs? Is this because there is some socialist, everyone gets a hand job, universal health care system in place or because there are financial incentives to develop such breakthroughs?

Mother econ wins every time. She's undefeated in the history of the world. Attempt to remove the incentives to from the medical industry and watch the quality of services rendered diminish overnight. Profits are good, greed is good.

@johnva: Natural selection, worked for Darwin, works for me.

@HIV 2 Elway: Does not "work for me", sorry. The profit motive "works" for the people with the power in the system, but it doesn't "work" if your goal is taking care of individual people. I believe the health of all our citizens is far more important than corporate profits.

Also, most "medical breakthroughs" discovered in the U.S. have little to do with profit and a lot to do with government funding of research. You didn't think the high cost of drugs and medicine was because of all the money they were plunging into R&D, did you?

@HIV 2 Elway: Then why the insurance company authorized coverage in the first place? Either they tell the truth and don't take your money; or they are lying and stealing from you.

@HIV 2 Elway: Define ''liability''. You seem as liability, let's deny you coverage? How are you going to evaluate who's liability and who's not? Once you're retired and lose your employer's coverage, I suppose you being old is a liability for any insurance company.

@HIV 2 Elway: The same could be accomplished by the goverment and (non-profit, taxpayer supported) universities doing the research.

It would be far more economical and reduce healthcare costs by eliminating the marketing, advertising, bloated salaries and lobbyist expenses involved in developing and selling a drug through current private corporate channels.

@johnva: Natural treatments are NOT well investigated, as most "peer reviewed journals" and other ways of publicizing research are controlled by the medical establishment that is more interested in protecting their own than in the health of the public.

As an example, it's been found that St. John's Wart is as or more effective than many prescription anti-depressants. Exactly who is economically motivated to champion this and do even more wide-scale testing and research? And yes, many medications come from plants and such, but only when the active ingredients can be synthesized and patented. Asthma? Relieved by increased hydration. Who's gonna fund that research?

The medical industry has no incentive to maintain or restore wellnes. That would eliminate their market. The medical industry exist to treat and manage illness.

@HIV 2 Elway: As for research, it has nothing to do with health insurance, NOTHING. Also, wait few years and observe how the research is gradually getting outsources by PHARMACEUTICALS companies.

Pharmaceuticals often finance a variety of researches in universities, in exchange for rights on whatever is discovered.

@SkokieGuy: Please stop making so much sense all the time, I can't stop swooning.

I *work* for an insurance agent that sells group health insurance and I had an evil time with Oxford/UHC. My five year old developed tremors in her hands, arms and legs, and none of her doctors could figure out what was causing it. Her neurologist thought that possibly she had a fatal genetic degenerative brain disorder and suggested a special blood test that is only done by three labs in the country - none of which are in network with Oxford/UHC.

Oxford/UHC has a special line for high selling brokers to help them with customer service. Prior to the test, I called several times to this line and spoke with them regarding this issue and was told that because they didn't have a lab that performed the test, I could do it out of network, it didn't require pre-authorization, and that they would pay it as if it was in-network.

This was my kid and time was of the essence so I laid out the money for the test and to have the blood overnighted to Kennedy-Kreiger's Lab. I submitted it to Oxford and was denied several times - because it was out of network, because there was no provider listed who ordered it (there was, her neuro is in network), there was no pre-authorization, etc.

We did that test in July 2007. It took three customer service reps in my office, two customer service people on the special broker line, seven months, two appeals through Oxford, a threat to appeal to the state, and finally, we asked for a favor from our Oxford salesperson.

What finally did it? The salesperson had them pull an override. Why? Because it looked very bad for her if one of her biggest brokers got upset about how Oxford treated one of the *broker's* employees.

The kicker? The test only cost $165. That's chump change for Oxford.

And no, thank g-d, she the test was negative. She doesn't have a fatal degenerative brain disease.

@Victo: Like I said earlier, our system right now is privatized profits, socialized costs. We allow private for-profit insurance companies to profit by cherry-picking the healthiest people to be their customers. This minimizes the possibility that they will actually have to pay out a lot in benefits. Then we have the taxpayers pay for the people who cost a lot (like the elderly through Medicare, the poorest of the poor (who tend to have more health problems) through Medicaid, and the medically uninsurable (through state high-risk pools)). This raises the average cost per patient of the government programs, because they naturally have the people who can't get private insurance. So basically we are bankrupting our government to allow for-profit insurers to make huge profits.

If, instead, we just put everyone in a single risk pool, the average cost per patient would go down because the healthier people would then be bringing the cost down for everyone. Our hybrid public/private system is incredibly wasteful AND a massive corporate-welfare scam on the taxpayers, healthcare providers, and patients.

@SkokieGuy: A lot fo the reseaerch is done by universitys and then the technology is then puchased by drug comapanies.

If you want to blame one faction in particular, blame the FDA.

@HIV 2 Elway: Nice sentence, asshole.

@alphafemale: Thank you for recognizing my latent brilliance. There are now two of us who agree.

40 years ago I was diagnosed as ADD (Now ADHD). My mother fought the doctors who wanted to drug me up. Now, 40 years later, we have school teachers and guidance counselors determining that if little Johnny isn't medicated into submission, he will not be allowed back in school. 40 f'ing years and we cannot manage what used to be called childhood. (Wow, kids have short attention spans, can be unpredictable and some times act inappropriately. Why in the new millenium, does this continue to suprise people and require drug usage to ameliorate)

So as a child, we have public schools demanding we drug children, (too young to give consent). Once those children grow up, if they want to smoke a joint (their own choice to self-medicate) we throw them in jail.

I generally have little patience for people who defend the status quo. There are very few things in life where we should accept and be satisfied with the status quo.

This does not apply to Ben & Jerry's ice cream, however.

@SkokieGuy: Look. My big thing is that I think these things need to be scientifically validated. I don't go for "belief-based" alternative medicine. If the effectiveness and safety is scientifically validated, great. But I do not believe there is any such worldwide conspiracy to keep "natural" (I'm not sure you're defining that in a valid way...everything is "natural") treatments out of peer-reviewed scientific journals. And I don't believe some things, like homeopathy, are even worth wasting research dollars on. Herbs and acupuncture, yes (though my understanding is that the pseudo-scientific theory behind acupuncture has been mostly disproven now...meaning it's a purely physical effect). Homeopathy, no.

And I feel you're ignorant of the vast amount of research that in fact is being done on various "alternative" treatments. As I said earlier, most research is actually done by universities and such, not private industry. So if the government will fund the research, it will be done, regardless of the profit motives or economic model behind it. It just might not get done at a private company...but then, these companies are doing less and less of their own R&D anyway. If you want this stuff to be researched, ask the government to fund it and vote for people that want to fund scientific research. No profit motive is needed then.

@SkokieGuy: There is nothing wrong with "challenging the status quo". That's what I do here and elsewhere in every one of these health insurance threads. But do it in a way that is grounded in reality and evidence. We need scientific guidance to do the best medicine. The profit motive actually distorts the scientific process in many ways. You touched on one way, and another is that for-profit enterprises generally don't like to fund expensive research with a long time horizon or a high risk of failure.

@johnva: I too believe in scientific and unbiased evaluation.

Our government has many documented cases of squelching or supressing science (many scientists in the FDA, Centers for Disease Control, EPA have all come out and acknowledged that have been pressured to change or modify data).

As one example, a recent widely publicized study discounted the efficacy of vitamin C. The study gave the entire dose at once time, which is a waste, because vitamin C is excreted in the urine. If the same daily quantity had been given, but spread out over the course of the day, the results would have been vastly different. Despite this obvious study design flaw, this study has been widely disseminated by maintstream media and mainstream healthcare. Why - because it tends to discredit the alternate health crowd, and tends to support the prescription health industry.

I could go on and I (I won't), but in addition, we have consolidated mainstream media, what, like about 6 companies? The healthcare industry, drug companies, insurance companies and such are a huge source of advertising revenue.

Just as there is little economic benefit to researching non-patentable health treatments, there is little economic benefit to reporting on succeses in this area or debunking mainstream health.

Computers have been used in the business world for what, like 20 - 30 years? Most doctors still hand-write prescriptions and exam notes in patient records. How on earth can this be justified? My local Jiffy Lube uses a higher standard of computer verification and bar coding. Talk about low-hanging fruit for cost reduction and reduction in medical errors (and lawsuits and deaths).

The healthcare community has gotten a pass for far to long from the mainstream media. Investigate journalism is dead, unless you want to know about the latest backstage scandal on American Idol.

The whole alternate health community knows about the criminal scandal involving the approval of Aspartame - Nutrasweet, yet only bits an pieces have every been reported in mainstream media.

@SkokieGuy: Your post reads more like an indictment of the government and the media than of the scientific community to me. I still do not believe that scientists are conspiring to suppress research into alternative medicine. If anything, alternative medicine is getting more funding than it merits.

I think you're looking at things selectively in a way that reinforces your bias here. The media reports on unproven alternative health woo all the time, so I really doubt your claim that they are suppressing the evidence in order to benefit the for-profit pharma industry or whatever.

As for computerization, yes, in some places it's pretty bad. The government is partly to blame for this, because it's often regulations and such that make computerization difficult. For example, HIPPA has extremely vague and complex data privacy rules that make it expensive and difficult for a doctor or hospital to go paperless.

@johnva: Scientific funding costs money. Most funding sources are either the government (owned by corporate lobbyists), or private drug companies.

No lawyer has a witness on the stand whom the laywer is not absolutely certain of what the testimony will be.

Who is a funding source for scientists to uncover the truth, no matter what it may be?

In Africa, they are treating AIDS with an extract made from the Oleander plant, a flowering plant that you might have in your garden. In small clinical trials, success rates are approaching 100%.

Have you, has anyone reading this thread heard of this? Seems to me, ought to be newsworthy.

A diagnosis of AIDS is a lifetime annuity for the drug companies. The NY Times reports $32,000 ANNUALLY to treat one AIDS patient. Where is the economic motiviation for a cure?

(Simply google oleander + AIDS)

@SkokieGuy: Prove to me that alternative health is not getting research funding. It is, and you're wrong if you think it isn't. Even without patents and such, it's still incredibly profitable, BTW. Look at how many people are willing to pay through the nose for various "alternative" treatments even with no evidence that they work or are safe.

There is always going to be some influence over researchers from the funding sources. But it's less than you might think, especially in academia.

@SkokieGuy: Stop obsessing about the "economic motivation". The government is putting tons of funding into AIDS research. They are not suppressing some miracle cure because it threatens big pharma interests. Do you realize how paranoid that statement sounds?

Don't feed the trolls, folks.

@johnva:

One tiny example: Cancer, 7,080 clinical trials, 123 into alternate modalities, 1.7% of total.
[www.naturalnews.com]

Prove to me that alternative medicine IS getting research funding!

And my last comment on this thread, because you and I could debate alternate vs. conventional medicine all day and night.

How about we agree that an industry that has life or death prescriptions hand written is in need of a wee bit of change?

How about we agree that the FDA that only requires drug companies to submit studies with positive results and does not require them to publish or supply other studies with negative results, and an FDA that employees top people from the drug industry - is in need of a wee bit of change?

@worksintheory: Your contribution was so valuable. Thank you.

@SkokieGuy: I never said the industry and the regulatory apparatus are not in need of change. It obviously is. I'm just against introducing nonscientific treatment as part of that. If "alternative" medicine can provide scientific support for their theories, great. Just don't push stuff that is based on pseudoscientific woo as an equal to scientific medicine.

Alternative health should not get the same level of research funding as more scientific stuff, because there is less reason to believe that most of those things will work. I support research into alternative treatments that have a plausible theory behind their possible effect. I don't support it into things that are based on discredited or made up belief-based theories of medicine (which is what a lot of alternative health is). And you can't just compare numbers of studies like that. You have to look at whether the particular things being studied MERIT being funded.