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Author: ThyPeace Big red star, 1000 posts Old School Fool Add to my Favorite Fools Ignore this person (you won't see their posts anymore) Number: of 308683  
Subject: Insurance claim question Date: 6/12/2011 10:54 PM
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I am sure there is a place to post this -- someone point me there and I'll crosspost, promise.

Simple question, basically. DD had a neurological assessment done earlier this spring, and was diagnosed with ADD and anxiety. She's also a smart cookie, but that's not so much of a problem as the other two. DD is covered under my ex's health insurance as primary and mine as secondary. My ex called and was told that she needed a pre-authorization for the assessment, and intended to do it, but forgot to before the assessment began. This is roughly the second time in the 22 years I've known her that she's forgotten something like this. We've been juggling migraines, the problems in school, eye focus problems, and a desperate need for braces -- there is just Too Much Stuff going on with DD and we've both gotten a little overwhelmed. The assessment also happened much more quickly than we thought it would, and that threw things off as well.

The insurance, of course, denied the claim and will not "pre-date" an authorization, or whatever it's called. They did recommend, or at least say -- I wasn't on the call -- that we file an appeal.

So I'm reading my ex's draft appeal, and I'm wondering whether anyone's done this before and if there are specific things that really help/hurt the case? So far, the letter basically says what I said above, with the addition of the array of stuff we're doing in relation to the diagnoses -- 504 plan, lots of interventions at school, additional counseling for DD and for us on how to help her, assessment for meds. In addition to the migraine meds and interventions, the eye interventions, and the not-yet-on-her-teeth braces. And the baby tooth that hasn't come out even though the grown-up tooth is now coming through the gum above it.

Lordy. I shouldn't write all this out at once like that. Totally makes me overwhelmed just to read the list. So my question, again, and I apologize for the ramble -- any advice or thoughts on what should be included or excluded from the letter? Thanks!

ThyPeace, $2,500 is a lot to pay on our own.
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Author: ThyPeace Big red star, 1000 posts Old School Fool Add to my Favorite Fools Ignore this person (you won't see their posts anymore) Number: 302359 of 308683
Subject: Re: Insurance claim question Date: 6/12/2011 10:56 PM
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Oh. And we also included an apology for screwing up their procedures. I don't know whether that's a good idea or not, but it is sincere.

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Author: alstroemeria Big gold star, 5000 posts Top Recommended Fools Add to my Favorite Fools Ignore this person (you won't see their posts anymore) Number: 302360 of 308683
Subject: Re: Insurance claim question Date: 6/13/2011 8:34 AM
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I can;t find a Health Insurance board, but you might try the Parents board:
http://boards.fool.com/parents-and-expecting-parents-112914....

There is an Insurance board, but it doesn't seem to cover health insurance:
http://boards.fool.com/insurance-life-car-homeetc-100156.asp...

The following boards are well trafficked, which might make them a good place for this topic--and I think your topic relates to all of them pretty well:

Living Below Your Means:
http://boards.fool.com/living-below-your-means-100158.aspx?m...

Political Asylum:
http://boards.fool.com/political-asylum-113502.aspx?mid=2935...

An Open Letter:
http://boards.fool.com/an-open-letter-117642.aspx?mid=293560...

{{{ThyPeace}}} and good luck with your daughter's health & treatment.

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Author: NoIDAtAll Big funky green star, 20000 posts Old School Fool Add to my Favorite Fools Ignore this person (you won't see their posts anymore) Number: 302361 of 308683
Subject: Re: Insurance claim question Date: 6/13/2011 8:40 AM
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It sounds like you've done about all that you can for now. I'd probably skip the apology and just thank them for their kind attention in the matter and to advise should they have any questions. Statements from medical professionals advising the necessity of the assessment would probably help. How will the appeal be handled? Will it be arbitrated before an arbitration board, with your picking an arbitration board participant, the insurer another and both deciding a 3rd person for the board? Check your policy for provisions on this matter. I'd probably CC a copy of the appeal request to your State Department of Insurance.

I am sure there is a place to post this -- someone point me there and I'll crosspost, promise.
http://boards.fool.com/insurance-life-car-homeetc-100156.asp...


Bob

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Author: NoIDAtAll Big funky green star, 20000 posts Old School Fool Add to my Favorite Fools Ignore this person (you won't see their posts anymore) Number: 302362 of 308683
Subject: Re: Insurance claim question Date: 6/13/2011 9:01 AM
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There is an Insurance board, but it doesn't seem to cover health insurance:
http://boards.fool.com/insurance-life-car-homeetc-100156.asp......


Yes, it does address health insurance issues and I respect the insights of a number of participants on the board.

I've been licensed as an agent in multiple lines of insurance, including Life and Health Insurance, since 1969. Health Insurance isn't my particular strongest field of interest, but I can address some questions pretty adequately. Some other participants to the board perhaps have more experience than I in Health Insurance, if they're watching it - The board has been pretty slow lately.

Bob

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Author: alstroemeria Big gold star, 5000 posts Top Recommended Fools Add to my Favorite Fools Ignore this person (you won't see their posts anymore) Number: 302363 of 308683
Subject: Re: Insurance claim question Date: 6/13/2011 10:11 AM
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There is an Insurance board, but it doesn't seem to cover health insurance:
http://boards.fool.com/insurance-life-car-homeetc-100156.asp.........

Yes, it does address health insurance issues and I respect the insights of a number of participants on the board.


Thanks for the correction--good to know (and have a rec :-)

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Author: Fuskie Big funky green star, 20000 posts Top Favorite Fools Old School Fool Ticker Guide SC1 Red Winner of the 2010 Rule Breakers Challenge Add to my Favorite Fools Ignore this person (you won't see their posts anymore) Number: 302364 of 308683
Subject: Re: Insurance claim question Date: 6/13/2011 12:35 PM
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At the risk of insulting those in the health insurance business, I would not count on a compassionate response asking an insurance company to overlook a failure to follow the procedural rules, to the contrary, any admission of that fact could be used as definitive grounds to reject the appeal.

Fuskie
Who is admittedly cynical when it comes to health insurance and thinks that given the facts presented, rather than focusing on a long shot appeal, OP should focus on not being left paying for someone else's mistake...

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Author: MetroChick Big funky green star, 20000 posts Old School Fool Add to my Favorite Fools Ignore this person (you won't see their posts anymore) Number: 302365 of 308683
Subject: Re: Insurance claim question Date: 6/13/2011 12:52 PM
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I don't have an answer for dealing with the insurance company, but if all final appeals don't end in your favor, I would call up the doctor's office, ask to speak with the office or billing manager, explain that you'll be paying out of pocket because you forgot to get a pre-approval letter, and see if they'll discount the bill or charge you what they would have netted from your insurance company if your insurnace were paying. That $2,500 bill might be what the office charges the insurance company, knowing it won't be paid out at 100%, and they might have a self-pay rate.

Also, if you do self-pay, your ex should make sure this amount gets applied to any yearly deductibles and/or maximum out-of-pocket amounts.

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Author: Patzer Big gold star, 5000 posts Old School Fool Add to my Favorite Fools Ignore this person (you won't see their posts anymore) Number: 302366 of 308683
Subject: Re: Insurance claim question Date: 6/13/2011 1:50 PM
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At the risk of insulting those in the health insurance business, I would not count on a compassionate response asking an insurance company to overlook a failure to follow the procedural rules, to the contrary, any admission of that fact could be used as definitive grounds to reject the appeal.

I concur. The procedural rules aren't there to improve care, they're there to reduce claims expense. Part of that expense reduction comes from not paying for necessary expenses when the subscriber fails to jump through the correct hoops.

Perhaps the insurance company will wish to appear magnanimous, and override the rules for people who call in and can demonstrate that the care was necessary. Or perhaps they won't. For the amount of money involved, it's worth your time to try. Just don't be surprised if it turns out that this particular company decides to stand on the procedural rules.

Patzer

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Author: determinedmom Big red star, 1000 posts Feste Award Nominee! Old School Fool Add to my Favorite Fools Ignore this person (you won't see their posts anymore) Number: 302367 of 308683
Subject: Re: Insurance claim question Date: 6/13/2011 1:55 PM
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Is this health insurance provided through ex's employer? If so, a call to the person who handles benefits for the employer may be helpful particularly if the insurance is really self-funded by the employer and simply managed by the insurance company. Before DH retired he had a couple of instances where he wasn't happy with how the insurer handled certain claims and he called his employer and then the ruling got changed.

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