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Appealing Out-of-Network claim

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Colorado213 Wife to husband diagnosed with "a severe case of HOCM" according to Dr. Salcedo at University Colorado Med Hospital HCM Center March to June 2014 I'm the main researcher and planner, so here I am! Mother to 3 young boys who will be tested in the coming months as soon as we get daddy situated. Find out more about Colorado213
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  • Appealing Out-of-Network claim

    I am in the process of appealing an out-of-network claim stemming from Justin's very first hospital stay back in March 2014. Turns out that even though we attended an in-network hospital (made sure on the way to the hospital via a phone call), there were several doctors who attended Justin over the four days that were out-of-network. Go Figure.

    So I've written a letter for the insurance (Blue Cross Blue Shield of Alabama-- I know weird when we live in Colorado) and I plan to cc the letter to the business that is making the claim (a group of physicians). Unfortunately I have to make "a payment" as it will go to collections due to the length of time an appeal takes (which is probably a deterrent for most to even bother trying).

    If we can get this reclaimed as in-network, I think, we will not have to pay anything as we have already met Justin's max out-of-pocket for last year.

    Any advice on this matter for those who have filed an appeal?

    Wish me luck!
    Megan, wife to Husband, Justin with HOCM
    Husband diagnosed at 37 when taken to ER due to CHF on vacation in San Diego at Pomerado Hospital, March 2014
    Seeing Dr. Salcedo in UC Med Hospital Denver upon diagnosis
    AICD/Pacemaker July 2014 @ UC Med Hospital, Denver with Dr. Nguyen
    Myectomy at Cleveland Clinic October 2014 with Dr. Smedira
    Parents to 3 boys, 11, 8, and 6 all currently clear from recent echos

  • #2
    Re: Appealing Out-of-Network claim

    You don't have to "make a payment" and let them send it to collections.....if it was at a network hospital, I would certainly have expected network doctors, and if they can't get it adjusted, I would tell them to "go fish"...actually I would tell them something quite a bit saltier than that, but some people here have sensitive ears. The day a professional turns me over to a collection agency, the gloves come off....think back to the original situation...did they do everything properly....if not a "friendly reminder" does wonders to get charges reduced. Some people may not like my approach, but its business NOT a moral issue. I can't tell you how many people I have worked through bankruptcy filings after they got clobbered with medical bills without having insurance coverage. You do what you have to.

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    • #3
      Re: Appealing Out-of-Network claim

      Call the both the HCMAs and the Drs. offices and see if you can pick someone's brain on this. I don't recall the reason for the stay, but it was in an emergency situation, its not like your going to verify each and every doctor's insurance participation before they render help. By going to an in-network facility you made a concerted effort to comply. And as for that payment, I think (not sure) that even a nominal payment shows good intentions - well, it used to! Sadly, Insurance is a pain and you often just have to keep at it. While these doctors have every right to not join the hospitals list of approved in-network vendors, its incidents like these that really annoy their staff & perhaps a nice chat with them can help guide you. All else, they may change the amount if you have to self-pay.
      Marc
      Diagnosed @ 48
      Saw Dr. Michael Debakey @ age 5 - "He's fine, just a little noisy"
      Father to 3 boys 22, 25, 29 (all currently clear - pending genetics)
      AICD - Valentines Day '08, Spark Plug replaced 11/14
      After much research, I had a Myectomy @ Mayo for my 50th Birthday '08
      Quietly going insane . . .

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      • #4
        Re: Appealing Out-of-Network claim

        I agree with the others. I had something like this happen a few years back - an ER visit and then admission to the hospital; a couple of weeks later, I got a bill saying that one of the docs who'd seen me wasn't in network. I wrote back to the hospital telling them more or less what Jordan suggested: go fish. I never heard from them again. Obviously, some hospitals might be nastier about this, but at least in my case, it worked.

        Gordon
        Myectomy on Feb. 5, 2007.

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        • #5
          Re: Appealing Out-of-Network claim

          Originally posted by gfox42 View Post
          I agree with the others. I had something like this happen a few years back - an ER visit and then admission to the hospital; a couple of weeks later, I got a bill saying that one of the docs who'd seen me wasn't in network. I wrote back to the hospital telling them more or less what Jordan suggested: go fish. I never heard from them again. Obviously, some hospitals might be nastier about this, but at least in my case, it worked.

          Gordon
          Let them be as nasty as they want to be....its hard enough dealing with the disease...we don't pick where we have an emergency need. I assume that most of us do our best to pay our bills, but there are limits both to our financial capacity and our sanity. THere is no down side to sticking up for ourselves when there is a need.

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          • #6
            Re: Appealing Out-of-Network claim

            So I received the last notice yesterday and the physicians billing department advised to cc the letter to them as well as the insurance company, but also to pay a $20 payment to avoid collections. I am not sure what to do as my instinct is to pay something to avoid collections as we have some of the highest credit score ever and would hate this to affect a large purchase down the line. I feel like I am being put on the hook for something we do not need to be dealing with, much less paying.

            Maybe I will call the HCMA office. perhaps they have good advice.
            Megan, wife to Husband, Justin with HOCM
            Husband diagnosed at 37 when taken to ER due to CHF on vacation in San Diego at Pomerado Hospital, March 2014
            Seeing Dr. Salcedo in UC Med Hospital Denver upon diagnosis
            AICD/Pacemaker July 2014 @ UC Med Hospital, Denver with Dr. Nguyen
            Myectomy at Cleveland Clinic October 2014 with Dr. Smedira
            Parents to 3 boys, 11, 8, and 6 all currently clear from recent echos

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            • #7
              Re: Appealing Out-of-Network claim

              I'd tell them that you went to an in-network hospital, even called ahead during an emergency to make sure they were in-network. You did your part. The hospital screwed up by using an out-of-network doctor. . . and didn't even tell you or your husband before treatment to give you a chance to accept or decline the out of pocket expense. It's bait and switch. Not your responsibility to pay for things that you didn't agree to and didn't even have knowledge until well after the fact.

              I wouldn't pay it. It will barely affect your credit score. And since your credit score is so high, you could not pay a lot of bills (not suggesting that you do so) and still have great credit. They are counting on you to pay because you are a good person that cares about your bills. . . but the hospital should cover it. I wouldn't worry about letters. I'd get on the phone and make some noise - a lot of noise.
              At least 5 years of symptoms.
              07/24/14: Age 45, diagnosed with HCM w/ obstruction.
              09/30/14: Tested at Cleveland Clinic (Ohio).
              January 2015: Approved for surgery.
              03/05/15: Pending myectomy & possible mitral valve replacement at Cleveland Clinic

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              • #8
                Re: Appealing Out-of-Network claim

                Thanks, guys! I talked to Lisa yesterday for some advice. She was super helpful (as always) and I went ahead with the letters to both insurance and the billing and I'll see what that leads us. Hopefully a resolution where we do not have to pay!
                Megan, wife to Husband, Justin with HOCM
                Husband diagnosed at 37 when taken to ER due to CHF on vacation in San Diego at Pomerado Hospital, March 2014
                Seeing Dr. Salcedo in UC Med Hospital Denver upon diagnosis
                AICD/Pacemaker July 2014 @ UC Med Hospital, Denver with Dr. Nguyen
                Myectomy at Cleveland Clinic October 2014 with Dr. Smedira
                Parents to 3 boys, 11, 8, and 6 all currently clear from recent echos

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