Appeal of denied health insurance claim

[beshara]

I was in the hospital twice last fall. Each time, blood tests were done. The tests were reviewed by a doctor who I never met, who forwarded the results to my treating doctor. According to the hospital, the reviewing doctor checks the test results as they come out of the machine because the treating doctor is too busy to do so. This is standard procedure at this hospital.

My insurance company is refusing to cover the charges of the doctor who reviewed the lab test results, saying his review was unnecessary. They say the results are machine-generated, and require no interpretation, other than by my treating physician.

Obviously, someone is wrong here. Either the hospital is right, and it was necessary for the reviewing doctor to review my tests, or the insurance company is right, and it was not necessary. In the former case, should the insurance company not cover the claim? And in the latter case, should the hospital not eat these charges?

My questions are these. First, how can I find out who is right, so I know who to proceed against?

Second, how can I prove my case? In other words, if the hospital is right, what can I do to make the insurance company pay (they have already denied my initial appeal)? And if the insurance company is right, how can I make the hospital eat the charges?

Thanks in advance for any advice you can give.

 

[lawrat]

Can you please repost in a shorter format. You will probably get a quicker response if you do. Also, don't forget to include your state.

thank you.

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I am a law school graduate. What I offer is mere information, not to be construed as forming an attorney client relationship.