Disputing Medical Insurance Claims & Payouts

Parent Q&A

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  • Attorney to fight health insurance company?

    (5 replies)

    I am wondering if there are any options for dealing with an insurance company denying a procedure. My mother (who lives in the South Bay) is being treated at Stanford for metastatic stage 4 breast cancer. She has a brain tumor, and her doctors have all recommended she have it treated with a type of radiation called a Cyberknife (she has had this treatment once before and it worked very well). Her insurance company (Valley Health Plan) sent her chart for a second opinion (by a doctor who has never actually seen or met my mother) and they concluded the brain tumor does not need to be treated. My mother's actual doctors disagree. She is filing a grievance with her insurance company--but I think she is going to need legal support to help challenge her insurance company.

    It feels a little bit like her insurance company is giving up on treating her because her diagnosis is terminal. However, at the moment she is still a very capable person and we are not ready to give up on treatment--especially when her doctors aren't recommending that.

    I have no idea where to start with this. If anyone can recommend a lawyer that works with patients against insurance companies or has any other advice that could help get my mom the treatment she needs, I would appreciate it.

    Thank you.

    I am so sorry you are going through this. No advice on a lawyer, but the podcast "Arm and a Leg"  recently had a couple episodes with a women who professionally fights insurance denials. There are a couple episodes with her where she provides concrete advice on next steps. This podcast has a lot of information about insurance, in general too. Here is the first episode: https://armandalegshow.com/episode/insurance-warrior-part-one/

    Have you contacted the Department of Managed Health Care? Did so if your mom is not on Medicare. Fill an urgent complaint. 

    Law office of Scott Glovsky https://scottglovsky.com

    Office is in soCa but they file complaints and lawsuits throughout CA. I gave personal experience w firm. 

    I'm sorry that you and your family are going through this.  Insurance companies are the worst.  The next step is to file a complaint with the California Department of Managed Health Care.  They oversee all insurance companies in California and they will get an independent medical review that will review what is needed and make a determination.  You can file the complaint online here:  https://www.dmhc.ca.gov/fileacomplaint.aspx  In my experience, they will contact you quickly to start the process.  

    Legal Assistance for Seniors in Oakland has a division called: Health Insurance Coverage Advocacy Program (HICAP).

    The health care manager (Brown and Toland) denied us.  We stopped there, but the information I looked up, was that the next thing was to file a grievance with the state, and that a person could request an urgent 3-day response.  I just wanted to back up their advice, because I think it is correct.

  • Anyone sue Anthem?

    (2 replies)

    Has anyone sued Anthem (and possibly UC) for denied claims? Got any lawyer recommendations for me? And yes, I've been in touch with the health care advocate, who has been sympathetic but largely ineffective.

    If your Anthem plan is an HMO I recommend you submit a grievance with the CA Department of Managed Care at https://www.dmhc.ca.gov/FileaComplaint.aspx .  I have pursued multiple grievances with them and found their lawyers to be compassionate and incredibly effective. I won all of them. They told me at least 60% of grievances are found in favor of the patient. Good luck.

    I have not sued Anthem but I would recommend that you go through the formal Claims Appeals process before hiring an attorney.  I have worked for multiple health insurance companies and the Claims Appeals process described here https://mss.anthem.com/california-mmp/benefits/coverage-decisions/appeal... is the best route. You may also need to get your health care provider involved to make sure they used the correct procedure codes when they filed your health insurance claim.

  • Kaiser's fees for services?

    (3 replies)

    The company I work for offers heath care through Kaiser.  With world events, we have been monitoring or expenses.  In late March I was in need of a minor procedure.  I contacted member services and was told based on the insurance plan I was on I would  have to pay over $4,000.  Going to a doctor on my own, the procedure would be around $250.  I talked to my primary care doctor who told me the $4,000 fee didn't sound right and to contact member services again.  I did, twice. I told them the exact procedure and both representatives me with my insurance coverage I would have to pay $125-$250.  That seemed reasonable so I made the appointment.  When I arrived, I was asked to make a $140 payment.  I asked if the $140 fee was for the entire cost of the procedure I was about to have.  The person taking my payment assured me it was.

    It's May and Kaiser is saying I owe an additional $543.  They are now saying the fee for the procedure is $683.  If I knew it was going to be that much I would not have had the procedure or gone elsewhere.  The doctor told me the procedure was easy and there ware no complications. 

    Member services told me they see my phone calls requesting the price.  They refuse to listen to the actual conversation I had with the representatives saying the notes say the $125 - $250 was just an estimate and that I was told there could be additional fees.  

    Member services is saying I don't and that Kaiser just under estimated the cost.This just doesn't seem fair or right to me.  Let me say the doctor and the care I received from Kaiser was wonderful. 

    Has this happened to anyone else? 
    Do I have any recourse?   

    Thanks

    I don’t work in the insurance industry, but have been a Kaiser member for 41 years so have some experience there.  It doesn’t sound to me that what you were told was incorrect.  You were given an estimate, which turned out to be wrong once the procedure was completed and bills submitted (internally).  If you’ve filed a grievance with Kaiser, you will have received your written documentation of their decision; all insurance companies are required by law to provide you with the contact information for the Department of Managed Care when a grievance is filed. You didn’t state, but it sounds like this may have been an elective procedure; Kaiser’s coverage for those won’t be as good as non-elective of course, so members are expected to have a higher co-pay then. Good luck to you.

    The only, and I mean ONLY way to get through for these things at Kaiser is twitter. They tried to charge me $3000 more than the quoted price for bunion surgery and I fought it for six months. Then tweeted at them, got sent to a billing specialist, NOT member services, and she fixed it.

    If you don’t use twitter, make an account just for this.

    I'm sorry this happened to you. Kaiser is normally much better about price transparency than other insurers/providers. I would recommend you reach out to the Benefits Manager at your employer. They have some pull with their broker to escalate this to Kaiser administration and may be able to help resolve it. You may get the same answer, but at least you'll have tried a different angle. Kaiser also has a claims appeal process, which I can't tell if you've officially gone through by your post. If you go that route, whatever the outcome is is final and you are obligated to pay if that is the determination. Good Luck!

  • Is there someone out there who is a whiz at dealing with health insurance? Tracking claims and doing appeals, etc? I am going crazy trying to do it myself and I find that my lack of knowledge on medical billing and insurance is making it difficult to get anywhere.  My frustration is beyond belief! Our situation is complicated and we have numerous enormous out of network bills (especially in mental health). Last year we spent about 129k on medical and I am fighting to get more of that money back- it has been bye-bye college fund and bye-bye to retirement fund. Our insurance carrier is Aetna.

    If you know how to do deal with insurance please contact me. I can pay or trade (pilates or photography).

    thank you

    Hi, if your health insurance is through your employer, sometimes they have sway with insurance companies (since they are the customer deciding to use that company) or they might have a broker or advocacy service available to help you. It's worth inquiring. It would be your employer's human resources department or benefits department that could help. I had a big problem once with insurance when I was on leave, and when I came back, the benefits team was like, why didn't you tell us, we could have helped? So maybe they can help you. Best of luck. 

  • Anyone have any advice on appealing a health insurance issue to the state? My child's mental health treatment was approved and then a few months in the insurance company denied payment because the practitioner is not fully licensed. I appealed to the company but they denied my appeal, now I want to appeal to the state but would love to get some advice first. If you would be willing to share any knowledge about the process or tips on a successful appeal I would be very appreciative. Thank you!

    I would suggest first confirming that you've exhausted the internal appeals available. There is often a second-tier appeal that is reviewed by a higher level person at the insurance company with a policy or regulatory role. Subsequently, you can appeal the coverage decisions by opening a case on the CDI website. While I've successfully challenged a number of coverage decisions, I don't have any experience getting coverage for unlicensed service providers. Generally speaking though, I would suggest that the persuasiveness of the arguments that you present in your appeal letter does have an impact on the outcome of your appeal.

    Is this an outpatient provider? I am an LCSW and was told when I was Pre licensed that MSW or AMFTs services are not always reimbursed by insurance. Many Pre licensed individuals offer sliding scales for this reason. I'm sorry this happened

    I’m sorry you’ve been struggling to get coverage for your child. The therapist should’ve been working under someone else’s license if he/she/ they are not licensed yet. Double check that there is no supervisor whose license can be used for billing. Otherwise, I don’t think you will win the appeal. If the therapist did not disclose that they are unlicensed you can ask for reimbursement from the therapist. There may be both legal and ethical issues involved.

    Make sure that you appeal the decision as high up as you can with the insurance provider, and also file a complaint with the provider. I filed a complaint with Kaiser and they immediately refunded my co-pay and bill for the service. 

    If that doesn't work, gather all the evidence you can of the treatment approval and then subsequent denial. Have paperwork from all the appeals and complaints, too. File an IMR here: https://www.dmhc.ca.gov/FileaComplaint.aspx

    I had success in appealing to the state once. An ambulance bill was sent to the wrong address due to a typo, so I never received it. Three years later, I moved and received the bill. Since this was after the 2 year window for filing claims, the insurance company, Blue Shield, denied my claim for the old bill. Appeals to Blue Shield were also denied. I filed an IMR. The decision was that while Blue Shield was within their right to deny the claim, it would be covered given the circumstances. 

    Good luck!

Archived Q&A and Reviews


Questions


Health insurance won't cover son's vision therapy

May 2007

Does anyone know if it's possible to get a health insurance provider to change their mind about covering something if you can make a good case? My 5-year-old son has had severe social problems (aggression, hyperactivity, explosiveness, extreme sensitivity) which has turned his life and ours upside down. After 18 months of research and endless attempts to evaluate and treat, we discovered he has significant vision impairments and is improving at a dramatic rate as a result of vision therapy. As was the case with a majority of the treatment avenues we've tried, our insurance doesn't cover vision therapy. We attend weekly appointments which cost about $500 a month and will likely continue for the better part of a year I imagine (we started 2 months ago). We're tapped out financially from all our other treatments and if I thought there was a way to appeal to my insurance company (United Healthcare), it would be well worth the time and energy of going through the appeal process. Is that even possible or is it an open and shut case with what they cover?

Someone told me if I could get letters from professionals that have been involved with his care (teachers, occupational therapists, his pediatrician, etc) that could express his need for help, his vision impairments, and his progress thus far, that they might appeal. Do they ever change their minds? If I were to build a case, who would be the best people to get letters from? What would the letters need to say to get their attention? Who would I send the letters to? If anyone has any experience with this I would love to hear about it, even if it's to say that I shouldn't bother. Thanks alot! anon


You didn't mention in your post if your child is seeing an OT right now, but an OT may be able to administer some of the vision therapy. My son was tested by the binocular vision clinic at Cal and in their report they recommended a series of exercises which were carried out by his OT at school. anon


Hi, the therapy we offer at the sensory learning center has vision therapy as one element. The question of insurance coverage comes up quite frequently. United has paid in the past, but it does seem that arguing your case well makes a difference. What works for our patients is: a) A referral from a licensed health care practitioner. b) A procedure code for the therapy c) Tax id for the therapy center d) date of birth for the patient e) health coverage # for the patient f) diagnosis code for the patient (usually a part of the referral) Even with all these in place, there is sometimes resistance. Persistance does pay off. Sincerely, Bryan


I'm not exactly sure what his Vision Therapy consists of, but my daughter required multiple Opthalmologist visits because one eye was much weaker than the other. She had to be checked at least every several months, and for awhile once a month. She wore a patch on her strong eye to try to force the weak one to improve (it did, significantly.) These visits were billed as medical rather than vision services and were fully covered by our health insurance at the time (Aetna). Our vision coverage provided for only one visit per year. If your son's issues are behavioral rather than medical you may be out of luck. However, if there is a medical component to the behavior problems you may be able to come at it from that angle. Sandi


HMO won't pay for alternative health therapies

March 2007

I would love some advice from anyone who knows how to go about appealing services denied by an HMO (Health Net) for (alternative) health therapies. Has anyone had any experience with this? Health Net has approved services for the western/ allopathic care (pediatrician, neurologist, prescriptions (which has very little to offer for my teenage daughter's ''transformed migraine'' and chronic fatigue syndrome) and deny the things that have actually brought releif (acupuncture, osteopathic manipulation, etc.) I would be grateful for any recommendations, names of professionals who could help, similar experiences, etc. Kris


Hi Kris, I understand your frustration. But unfortunately, if it's not written in your policy, then the insurance company doesn't have to pay and the likelihood of getting them to pay is close to none. Double-check your policy. If they cover procedures that are like these, then you may want to ask your doctors / actupunctursit, etc. to amend the writing of the treatment in your claim. I don't mean lie. But sometimes insurance companies will only cover something that's stated with specific language and procedure. You can have had that treatment, but the insurance company won't pay because of how the claim is written. But essentially if the insurance company doesn't cover these procedures, you may want to look for another provider who does. Anon


Insurance won't pay for anesthesia for child's ear tube surgery

Jan 2005

I have Blue Cross/Blue Shield PPO medical insurance. Under the terms of my plan, I have minimal costs associated with medical procedures so long as I use a ''preferred provider.'' In addition, I am not responsible for the difference between the billed amount and the allowed amount negotiated by my insurance company so long as I use a ''preferred'' provider. Last May, my daughter had ear tubes placed in her ears. We selected to ''preferred'' surgeon and a ''preferred'' hospital (Children's Hospital Oakland) Unbeknownst to me, the hospital outsourced the anesthesia for my daughter's procedure to a ''non-preferred'' anesthesiologist - who then promptly sent me a bill for $540. My insurance company sent me a check for $150 which was 90% of their allowed amount for a ''non-preferred'' provider and says that I am responsible for the difference. Needless to say, I'm outraged. I did everything I could to maximize my insurance benefit but now I am required to pay almost $400 for anesthesia - which by the way is more than double what I had to pay for the entire surgery. I have already appealed and lost the benefits determination with my insurance company. Does anyone have any advice on what I can do about this or am I just stuck? Thanks. anonymous


There is a department of insurance in California. I don't know if it will oversees your medical insurance, but it might. They are there to help you get treated fairly by the insurance companies, and complaints to them go on the insurance company official records. You should get useful help if your problem falls under their auspices, they just helped us out after a 4 month nightmare of arguing with our insurers and feeling powerless to get them to do their job. www.insurance.ca.gov anonymous


Boy do I know what you are going through. I had a similar situation with the birth of my second child. It turned out that the pediatrician who happened to be on to check my baby when she first came out was ''out of network'' despite the fact that the hospital is in network. My friend had a similar situation when she went to the emergency room at a network hospital and the doctor who happened to treat her wasn't ''in network.'' I don't know what insurance companies expect you to do in these situations. Was I supposed to stop the doctor from checking my newborn and before I had even delivered the placenta get on the phone and talk to some insurance company bureaucrat to check her credentials? In my case, eventually the insurance company paid, but it took a long fight, with the help of my HR person at work, and in the end they acted like they were making a special exception for me in allowing me to do something not allowed by the policy. My only advice is to not accept it and keep fighting it until they give in, but I would love to hear if anyone else has any advice about changing this ridiculous situation overall. Fed up with health insurance companies


If Blue Cross/Blue Shield has already determined you a responsible it is probably just an expensive lesson in just how uch homework you have to do when dealing with a PPO. At a fraction of the cost I also learned the hard way with my 'PREFFERED'' provider who did lab work for me and sent it out to a non-preffered lab. At length I discussed the situation with my preferred provider facililty who in the end didn't cover an of the cost for me but did ask more questions about insurance before making assumptions. Unless you are willing to ''go all the way'' and get a lawyer etc. involoved I am not sure that you have much choice, I would certainly talk to Children's Hospital and make sure they are aware. kriz


The Medical Board of Calfornia offers services to consumers that deal with quality of care to dishonesty issues. This group has made things happen for both me and my wife. I believe that the insurance company's front line people are often told to deny claims, coverage, or complaints as many consumers just drop their issues then. Check them out, and then follow through. It can be a lengthy process but worth going through the exercise. http://www.medbd.ca.gov/complaint_info.htm Jeff


We have this exact same problem right now. In August, we landed in the Children's Hospital ER with our one-month baby who, as it turned out, had pyloric stenosis. He was very dehydrated because of all the vomiting (it will take me years to get over the guilt of not taking him in sooner, but I thought he was just spitting up alot, ugh). He is totally fine now. Everything was covered as ''in network'' in our Blue Shield PPO plan. Just this weekend, however, I got a bill for over $1300 from the anesthesiologist. Apparently, although the hospital, the surgeon, the ER doctors, the primary care doctors, etc., were all part of the PPO plan, the anesthesia group is not ''contracted'' with Blue Shield. Of course, we had absolutely no way of knowing this, and no one ever said anything to us about choosing our own anesthesiologist. In fact, we had absolutely no benefits counseling whatsoever. So, I called Children's Hospital today, and eventually spoke to an ''in patient'' representative who was somewhat helpful. She told me that because our baby was admitted through the ER, the insurance should pay the claim at an ''In network'' rate. This is apparently because we had no way of knowing anything about or choosing our own doctor (duh). She told me to dispute the claims processing with the insurance company, and that they might pay more. I am not sure how this will turn out. I suspect an unfair business practice by someone (the anesthesiologists? the hospital? the insurance company? not sure, but consumers are the ones getting screwed). If you want to email me directly about this issue, feel free. xialiu


If you filed a grievance with your health plan and got nowhere, try filing a complaint with the Department of Managed Health Care at www.dmhc.ca.gov. --Sounds shifty to me


I actually had almost exactly the same thing happen to me a few years ago. I had to have surgery for a broken ankle. I have Blue Cross and I researched a Blue Cross hospital (Alta Bates), a Blue Cross surgeon, then the hospital used a non-Blue Cross anesthesiologist who insisted that I pay the difference b/w what Blue Cross paid him and what his actual fee was, which was several hundred dollars.

Anyway, I was outraged as well, especially since the insurance company agreed with me that I had no choice over the anesthesiologist chosen. After numerous outraged phone calls I finally ended up talking to a woman at Alta Bates who was familiar with this situation and who told me to call Blue Cross and ask for some kind of special exception based on the circumstances....she gave me a catch phrase to use which unfortunately I can't remember exactly....which allowed them to treat the doctor as if he was a blue cross doctor. Anyway, I promptly called back and used the phrase with Blue Cross only to be told that they didn't use that kind of exception in CA (can't remember why). To which I of course said that my Blue Cross hospital just told me that you could. Then they finally caved and said OK and paid the anesthesiologist.

Anyway, what to recommend? Perhaps call Alta Bates and try to get the exact wording of what you sould tell the insurance company? Sorry I'm a little vague on the details, but the upshot is, I didn't have to pay the anesthesiologist bill. Been there with Blue Cross


Although I'm sure there are some pieces of info missing in your story this is what I can tell you. First, Childrens hospital does not outsource any of it's anesthesia services. The anesthesia is 100% pediatric anesthesiologists who are part of the Childrens Anesthesia Medical Group. All members of the group are part and parcel to the contracts with the insurer, in this case blue cross/shield. You need the insurer to tell you first of all whether or not they have a contract with the CAMG medical group (the anesthesiology group). The answer should be yes. Then ask them why the particular member of the group who did your childs anesthesia is not considered a preferred provider. I suspect they will review this and see they made an error. Sometimes the lower level agents at an insurer will pass on some erroneous piece of information such as the ''outsourcing statement in order to explain a billing mistake. dave


At the very least you should contact the appropriate government agency or agencies regulating your PPO. I don't know who that is, but the CA Dept. of Insurance and the CA Dept. of Consumer Affairs would be two good places to start. If that fails, call your assembly member or state senator. Sometimes merely the threat of regulatory action is enough to convince a business to treat you fairly. David


We had the EXACT same thing happen with Children's Hospital. And, my son had an emergency appendectomy - like we had a choice on the anesthesiologist! I battled with Blue Shield and they did pay at the higher rate, minus my deductible. It wasn't great, but better than what you got. Get your insurance broker involved. Their intervention I've found works wonders. Keep being persistent. Last resort, negotiate a reduced fee (what the insurance would have paid) with the anesthesiologist. I'm so sorry this happened to you. got the insurances blues...


I also have been caught in this billing catch 22 between my health care plan and the Anesthesiology group at Children's Hospital. It sadden's me to read about all the others who were caught when they were at thier most vulnerable with a sick child. You can(with preserverance)get your health plan to acknowledge that you did not have a choice of anesthesiologist and they will pay out at the preferred rate. That does not obligate the Anesthesiology group (other than ethical obligations perhaps) to accept that as payment. And they won't. Why should they? They have a monopoly on the service and you are just one person. You can check your provider. You can check your hospital. That just leaves everyone else. How many folks get caught in this predatory business practice? The CEO of Children's Hospital is Tony Papp. The e-mail address of the head of the Hospital charitable foundation is Mpetrini [at] mail.cho.org. The email address of the head of the anesthesiology group is maustin [at] mail.cho.org. Hope this helps. Robert


I was surprised to learn that so many people have been going through the same thing! My son has been treated at childrens hospital Oakland now and he needs to have surgical procedures quite often. We have a health insurance (United Healthcare), and I am dealing with exactly the same thing. While Childrens Hospital, my son's oncologist, and lab work are in network, my anastegia fee and fee from sergical center (clinic?) are out of network. What I have learnt by talking with insurance company is that they have an exception called SAP (Surgery, Anastegia, and I forgot what P stands for). If SAP was performed with in-network doctors at the hospital (or ER) which is also in-network, SAP is also considered in-network and should be covered as in-network. It is because my son had no choice but to go with those anastegists who are out of network, because they work in the same in network facility (in this case, Childrens Hospital Oakland) with in-network doctors. Maybe you can ask your insurance company to see if they have this SAP exception policy. My son's case has not yet been resolved, and I may have to move on to request an audit (they processed our claims as out of network first, and I am requesting them to handle those claims as in-network) but that is supposed to be a policy (and my right to receive coverage). Mika


Insurance is refusing claims for the doctors I go to

August 2001

I've got a problem in need of legal backing. Basically I started work with a new employer, specified who our primary health care providers should be within the medical plan (PacifiCare), but somehow the employer didn't transmit the correct information to the medical plan. End result - I have tons of medical bills and the plan doesn't want to pay because they say we've been going to the wrong doctors (though no one ever said anything - doctors, medical plan, etc.) Can anyone recommend a lawyer I can get an initial consultation with to see can be done? Jonathan


I couldn't get the whole picture from your posting, however, we recently got ourselves out of a similar situation. My primary physician and his group were no longer in my PPO, however the office never told me (so the bills added up). A second issue was a lab bill that wasn't submitted in time. Bottom line we were able to talk to my husband's employer who was able to authorize an override to the administrative company to go ahead and pay these bills anyway. Feel free to email me if you would like to discuss this further. I have a couple of friends with medical insurance experience who were able to help me. You may not even need to hire an attorney for your situation. Felicia


If your health plan is an HMO, it's worth contacting the Department of Managed Care's HMO Help line. You can call (888) HMO-2219 or (877) 688-9891 (TDD). Also, check out the agency's web site, www.dmhc.ca.gov You might also call Bay Area Legal Aid (BALA) for a referral to a private lawyer versed in employment and health care issues. In Alameda County, the phone number for BALA is (510) 663-4744. In Contra Costa, it's (510) 233-9954. Ellern