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The Company Helping America's Health Insurers Deny Coverage for Care

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Re: The Company Helping America's Health Insurers Deny Coverage for Care

#11
A few years ago, as my rebellion ramped up, I enrolled in a Christian Health Sharing Ministry. They published extensive disclaimers, telling members, "THIS IS NOT INSURANCE. DO NOT TREAT IT LIKE INSURANCE. WE RECOMMEND THAT YOU CARRY REAL INSURANCE."

Of course, I couldn't afford both the Health Share and real insurance, so I took the risk. But it soon became apparent that I was in over my head.

I barely understood the whole insurance claims/billing process. I had not been too involved, since Medicaid coverage had made a lot of that effortless and invisible.

So I had to learn about all these billing practices, and what's more, the Health Share had their own terminology that was parallel, but not equivalent, to insurance terminology. Thankfully, they published a detailed Lexicon document, in addition to their Sharing Guidelines.

All claims (Medical Needs) were manual. No providers would directly bill the HSM. The bills they sent to me were useless for this purpose. I needed to cajole each provider into generating an itemized "SuperBill" with all the info required for the HSM. Then I'd submit it to the HSM and literally pray.

I put up with this for a couple of years. I heard from other people how draining it was to deal with all this. So I finally withdrew. Now I carry regular Marketplace insurance.

But I'm descending into a hellscape of bureaucracy, and I'm scared of it. For years I've been trying to advocate for my health and reduce my health care costs by refusing unnecessary treatments that were making me sicker, and worsening my conditions.

But the insurance company seems hell bent on sending me on fool's errands and wild goose chases. For example, I didn't receive any billing communication for two months. Then, AutoPay failed last month. They sent me incorrectly-worded warning notices. I went around and around with CSRs about this. Finally we kicked the can down the road. They assured me that my insurance wouldn't terminate as it had been threatened.

But now my PCP's office is coming back to me with denials from 6 months ago. I'm tearing my hair out. Indeed, why do I need to be in the loop? They are filing claims. Their billing department needs to work this out. I'm powerless to tell my [ex-]insurance carrier what to do. I already sent them proof of coverage! Leave me alone!

It's a nightmare, and I predict that it will eventually eat my entire life. Many elderly people are slaves to their physicians and specialists and medications. My own parents are on a constant treadmill of doctor's appointments, every week, blood draws, ridiculously complex medication rituals.

My sanity and faith in Christ is worth far more than cooperation with these mendacious, lying, thieving swine. Mark my words.

Re: The Company Helping America's Health Insurers Deny Coverage for Care

#13

Evicore is a highly suspicious company, and the story of the patient who passed away in this article is sad. But I have noticed insurers do this (false claim denials) all on their own too. I and many friends have experienced Aetna routinely denying things that are explicitly covered by their plans and mentioned in the plan documents. They force you into an exhaustive cat and mouse game of chasing their team to reproc…

It's not even just insurance companies. My wife and I had a child earlier this year, uncomplicated natural birth, fully covered under insurance. However the hospital initially filed the claim incorrectly, causing the claim to be denied and us to receive a bill in the thousands well in excess of our deductible/coinsurance. Hours of phone calls to insurance and hospital later, we think we have it resolved but are infor…

Our situation and many friends is the same thing - uncomplicated birth. There was no error in how the claim was filed - just an unexplained denial. Which then led to a long drawn out process that required time and stress. All when you’re trying to focus on your child. I think insurance companies like Aetna target new mothers in particular, knowing they’re too busy and exhausted to deal with hours of phone calls. We deserve and want compensation for that time and stress.

Re: The Company Helping America's Health Insurers Deny Coverage for Care

#14

It's as if you need insurance for the insurance. Does anyone know if this service exists? E.g. if they deny, you don't even talk to them, you forward it straight to your insurance insurance and their lawyer instantly threatens to sue them?

It does! It's called supplemental insurance and is specially for when insurance denies your claim. It's quite nice since the event is simple to get covered. You have the denial letter from insurance and a statement from your doctor that says it's medically necessary and you're done.

Re: The Company Helping America's Health Insurers Deny Coverage for Care

#15
post #8

Earlier quoted context omitted.

It's not even just insurance companies. My wife and I had a child earlier this year, uncomplicated natural birth, fully covered under insurance. However the hospital initially filed the claim incorrectly, causing the claim to be denied and us to receive a bill in the thousands well in excess of our deductible/coinsurance. Hours of phone calls to insurance and hospital later, we think we have it resolved but are infor…

> There should really be a law that makes institutions liable for such errors. Does there need to be an explicit law? Could one sue in small-claims court for the time and expense damages?

This reminds me of the recent Disney+ arbitration case...

https://lawandcrime.com/lawsuit/borders-on-the-absurd-dead-w...

Re: The Company Helping America's Health Insurers Deny Coverage for Care

#16
post #14

It's as if you need insurance for the insurance. Does anyone know if this service exists? E.g. if they deny, you don't even talk to them, you forward it straight to your insurance insurance and their lawyer instantly threatens to sue them?

It does! It's called supplemental insurance and is specially for when insurance denies your claim. It's quite nice since the event is simple to get covered. You have the denial letter from insurance and a statement from your doctor that says it's medically necessary and you're done.

Do you have an example provider/plan?

Re: The Company Helping America's Health Insurers Deny Coverage for Care

#17
post #14

Earlier quoted context omitted.

It does! It's called supplemental insurance and is specially for when insurance denies your claim. It's quite nice since the event is simple to get covered. You have the denial letter from insurance and a statement from your doctor that says it's medically necessary and you're done.

Do you have an example provider/plan?

I don't know the specific plan since it's through $employer but it's through Aflac. I actually hope my insurance denies me now because it's better, they pay in full and I don't have to be in-network.

Re: The Company Helping America's Health Insurers Deny Coverage for Care

#18
post #8

Earlier quoted context omitted.

It's not even just insurance companies. My wife and I had a child earlier this year, uncomplicated natural birth, fully covered under insurance. However the hospital initially filed the claim incorrectly, causing the claim to be denied and us to receive a bill in the thousands well in excess of our deductible/coinsurance. Hours of phone calls to insurance and hospital later, we think we have it resolved but are infor…

> There should really be a law that makes institutions liable for such errors. Does there need to be an explicit law? Could one sue in small-claims court for the time and expense damages?

Fun thing about small claims (once had to sue a bad landlord, eventually settled out of court), even if you win you have to extract payment. That means you need to figure out which banks have which accounts you want to garnish and contact them, which properties to put liens on, etc or hire a collections firm to do that.

I suppose an institution might be more willing to just pay up and be done with it, but if they want to make it costly they very much can, even if the judge immediately sides with you. Often negates what you would have "won", particularly if you factor in time.

Re: The Company Helping America's Health Insurers Deny Coverage for Care

#19
post #8

Earlier quoted context omitted.

> There should really be a law that makes institutions liable for such errors. Does there need to be an explicit law? Could one sue in small-claims court for the time and expense damages?

Fun thing about small claims (once had to sue a bad landlord, eventually settled out of court), even if you win you have to extract payment. That means you need to figure out which banks have which accounts you want to garnish and contact them, which properties to put liens on, etc or hire a collections firm to do that. I suppose an institution might be more willing to just pay up and be done with it, but if they wan…

If nothing else, I assume it could defray any ostensibly-legitimate costs the hospital or service-provider is demanding from you.

Re: The Company Helping America's Health Insurers Deny Coverage for Care

#20

It's as if you need insurance for the insurance. Does anyone know if this service exists? E.g. if they deny, you don't even talk to them, you forward it straight to your insurance insurance and their lawyer instantly threatens to sue them?

Some employers will have healthcare concierges that help with resolving such issues. An example is HealthAdvocate[1] (no relation). I believe some of these services will take a cut (e.g. 25%) of the money they save for you.

I cannot speak to how effective these services are. My general experience with "proxy" services have not been great, due to inadequate care or training.

[1] https://www.healthadvocate.com/site/product-index/engagement...

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