Insurance appeal

[sathishav]

State : Michigan

Hello,

My daughter was admited in the ER on Jan 24,3004 as she had high temperature and low pulse. She was diagonised for UTI and we were there for three days. 2 days back I got a notice from my insurance company asking me to pay $6192!!.

When I checked with the insurance, they said my plan covers 100%, BUT I have to call and inform them before or during the admission, if not I have to pay 50% which is $6192 Unfortunately I was not aware of it. When I phoned them, the cus. rep. asked me to send in an appeal.

I am not sure how this is going to work out. Has anyone faced this before? Which is the best way to write, if I need to get relief from the amount? Any advice is greatly appreciated.

Thanking In Advance,

Sathish

 

[MellowCat]

I don't know what type of plan you have (HMO, PPO, etc) but here's my advice: Pull out a copy of your benefits booklet and see if the plan holds you (the policyholder) responsible for obtaining prior authorization for in-patient hospital services. If you are responsible, then you are probably out of luck. But...

Normally, an "in-network" facility handles prior authorizations on the patient's behalf. If they fail to obtain the authorization as required, they must write off the balance. I see this all the time which doesn't make sense, as its in the best interest of the hospital to obtain the authorization so they will get paid. I have seen only one plan that actually required the patient to obtain prior authorization themselves - I appealed it and won, even though the patien't policy specifically stated the policyholder was responsible for obtaining the auth.

If you decide you need to send an appeal, simply state the facts as you see them. However, if you were indeed responsible for obtaining the authorization, I don't think the ins. co. will have any sympathy for your "ignorance" of the plan requirements, but it sure can't hurt to try.