Just wondering if anyone on here has any experience appealing an insurance claim that’s been denied. On Friday 5/31 I started hemorrhaging at 14 weeks pg. I’ve lost 3 prior pregnancies since Nov 2017 and with the amount of blood was sure the pregnancy was over. I presented to the ER and baby seemed fine, but it was midnight by the time we got all the results and the doctors decided to keep me overnight and admitted me. I got a letter from Cigna today saying the overnight stay was not medically necessary and they’re not going to pay or even count what we pay against our deductible. I’m going to call my doctor tomorrow, but I’m wondering if anyone has successfully navigated something like this in the past. Was there anything that seemed to help? I have no idea how to prove medical necessity except maybe to bring up my history of losses.
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In my short experience in a doctor's office, if you can get the doctor to do a peer to peer it helps often. I'm not sure how that works with the ER vs the surgeon's office I work in.
I hope they accept the appeal.
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@Sams Mom: Thanks. The ER bounced me up to L&D pretty much immediately (which was scary AF at 14 weeks) so I was seen by my OB instead of an ER doc. Maybe if I call she’ll be able to reach out on my behalf.
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@karenbme: your OB would be the best person to explain everything if you've been with her through all your past losses.
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Have you talked to Cigna yet, like an actual person? I’ve had pretty good luck calling UHC (hopefully Cigna is similar), the reps have been helpful in guiding me, both themselves trying to fix it (whatever they can submit) and also helping me file formal appeals with supporting documents. I’d start there and not take the letter too seriously for now ... my experience is they always try to screw you at first, but with some time and persistence you can fight it. Good luck!! I HATE this stuff and that it is necessary.
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I agree that reaching out to your OB would be the most helpful. I’m a provider and write appeals fairly often. It’s part of our job and we want to help you! Plus it really pisses us off when someone WHO WASN'T THERE AND DOESN’T KNOW OUR PATIENTS says our decision wasn’t “necessary!”
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I don’t have any advice, but this is disgusting, I’m sorry you have to deal with it, and I’m glad your baby is ok.
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I have faught ambulance bills where my insurance said that it was out of network and I called and said well 911 was called, how exactly was i supposed to verify if the ambulance was in network. I would call your insurance, I know a total pain and ask what they need to prove it was medically necessary. If you are polite and acting like you want to help solve this and have patience you might be able to get it covered in some way.
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no experience, but so outrageous, i'm sorry you're dealing with it. what DOES qualify as medically necessary if not a decision that a doctor makes based on their medical judgment?! really hope your OB can help. this feels like one where you should really be able to successfully appeal but it sucks you have to expend the effort to do it.
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My provider has mentioned in the past that if insurance denies a claim, to let them know and they will fight the good fight and usually win. So definitely enlist the help of your provider. Sorry you have to deal with it, incredibly annoying, hopefully your provider can facilitate things.
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How the F were you supposed to know it wasn't "medically necessary?" Were you supposed to call your insurance company and ask if it was OK for you to stay after a doctor in the hospital told you to stay?? This makes me ultra ragey.
Call the insurance company to find out what the process is and loop in your doctor's office. In my experience, this will usually get resolved in your favor, but it sucks that you need to put in the time/effort.
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So not quite the same, but the anesthesiologist at my hospital with LO2 was considered out of network and the insurance wouldn't pay anything. The doctors office actually called me, told me exactly what to say to the insurance agency and helped me get it covered.
I would definitely call your doctor first, the billing office is usually extremely knowledgeable and can definitely help you get it covered.
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So, not L&D/OB, but EM doc who often sees people for the same. We wouldn't typically admit someone for Obs unless there was concern for on-going hemorrhage and potential need for transfusion, or on-going pain/nausea/vomiting that needed to be managed. The insurance companies look at the ICD-10 codes and check to make sure certain codes that they deem warrant admission are present. If they aren't, they send an automatic denial. I suggest trying 2 things:
1) Contact the OB who admitted you and let them know this is going on. If there wasn't truly a reason for you to stay overnight and they were doing it as a convenience or favor, then they may not be comfortable adding additional ICD-10 codes as this would be fraud. If in fact they were concerned about some of the above and just underdocumented which is most often the case given how taxed for time MDs are these days, he/she may have no issue adjusting their documentation to reflect the true need for stay. Once that's done, you ask them to refile with Cigna.
2) Ask for peer to peer review as others have said. When I've had denials reversed, it's either because I know the standard of care for a particular issue (like when my daughter had an ALTE and received CPR) and was able to press the matter as a knowledgeable medical professional, or had my daughter's MD do a peer to peer (when they denied her hearing test after ENT had diagnosed her with hearing loss 2/2 prematurity).
It's a complicated and shitty system. It sucks, but if you put in the legwork, justice usually prevails.
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Can your OB/the hospital code it differently? I think sometimes the issues arise when something isn't coded in the right way. Usually doctor's offices are willing to work with you since it means they still get paid.
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Definitely call your provider because if they're denying covering it for you, that means NO ONE is getting paid (hospital, OB, etc) by CIGNA so the provider literally has a vested interest in getting the decision overturned. Also, while they denied it as not medically necessary, did they assign the balance to you? That is called balance billing and it is illegal in some states. So, read the letter carefully and see if you are being billed. They could just be advising you of the decision, but then it is really all on the provider to fight the decision because they cannot assign the balance to you. If the balance is being assigned to you, call CIGNA and find out what information they need and then call your provider. I would bet this will eventually be covered. But, still super annoying to go through.
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Thanks, everyone, for the advice. I left a message at my OB's office on my lunch hour today and am waiting for a call back. Luckily, the doctor who was on call was the same doctor who's handled 2 of my 3 losses so I know her very well and she knows all the sh*t DH and I have been through. To answer things more specifically:
@bhbee: I haven't talked to Cigna yet. I did get a voicemail last week, but assumed it was a call about how to use my coverage less (I've received these, offering advice on how I can save money by not going to the doctor, after each of my losses). So I didn't answer or call back, but will call once I've spoken to the OB's office.
@yellowbeach: I do think the doctor was worried about continued hemorrhage (I was still bleeding and there was a lot of blood in my uterus). She gave us lots of scary information about how they would do everything up to and including transfusing me if needed as long as there were still fetal heart tones. And I was restricted to clear liquids from when I came in at 7pm until morning (when I had mostly stopped bleeding) in case I needed a d&c.
@poppygirl15: Cigna didn't assign anything to me, but said in the letter that the hospital couldn't bill me for services deemed not medically necessary, which doesn't seem like a thing the hospital would do--just say, essentially, "Cigna disagrees, so it's on the house." Especially since I signed a paper when I was there saying I agreed to be liable for any charges not paid by my insurance. I haven't seen a statement from the hospital yet for any of it (and it's not in their portal) so I have no idea what my liability might be.
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@karenbme: If CIGNA has said that the hospital can't bill you then you, personally, should be fine. It's not that it's "on the house," it's just that CIGNA recognizes that patients don't have control over whether they are admitted (you're not a medical professional) and, therefore, it's on the provider (who made the medical decisions) to fight it out with CIGNA.
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I agree with the above advice. You need to call and speak to someone at your insurance company first. I was able to appeal a denial for an ambulance (it was not 911 but a hospital transfer that I did not coordinate). The person I spoke to at the insurance company gave me some advice on how to file the appeal and I got a letter from the lady at the hospital that had coordinated the ambulance for us to help support our claim.
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Do you have any other choice but Cigna next time open enrollment comes around? That is freaking insensitive that they call you on how to save money by saying not to go to the doctor.
Does Cigna have online messaging? I think you would be better with written communication so you have a record. That is what I have done for my appeals.
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I would call and say What do you need from me or my doctor to prove that my stay was medically necessary? I don't have any human experience with denials but a lot for my pet insurance and all we had to do was have our vet provide supporting documentation. Try not to take the form works personally; they just need some documentation and your doc will help you with that!
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@Ms. RV: Unfortunately this is really the only viable option. Both DH and I only have one option at work and his is 2x the cost without any real difference in coverage level. But it’s easy to let a call go to voicemail, (and they phrase it in a much more pc way than I did).
@Bluemasonjar: @Elizabear: Thanks, I got another vm from a rep at Cigna while in a meeting today, so I’m planning to call back tomorrow and see what it’s regarding. It’s weird because there’s nothing in these voicemails to say what they’re calling about, which makes me skeptical.
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Just wanted to update—I spoke to the OB’s office at my next appointment and it turned out to be a coding error. Because I was there less than 24 hours it should have been billed as outpatient observation instead of inpatient. Found out today that after the coding was changed the claim was approved. Which is good because the hospital bill was going to be almost $5000. I’m still going to be responsible for a decent chunk, but at least it’s counting towards/will put me over my deductible.
Thanks to all who responded and encouraged me to speak to the OB!
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@karenbme: Excellent news! (sorry I'm just catching up 5 weeks later)
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@karenbme: that sounds super frustrating that you had to deal with that stress. Glad it got resolved. That's what ofv the things I really dislike with our healthcare system, all the billing and stress related to it.
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