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Discussion Starter #1
So DS had an EEG done a few weeks ago to find out if he was having seizures. I just found out our insurance (Aetna) denied the claim stating they don't cover "experimental or investigational" services. I honestly feel sick because the bill for this is over 5K, which we don't have. I am so disgusted by healthcare in general. Today we drove an hour round trip to an eval (part of ASD eval) waited an hour in the waiting room and then were told the OT wasn't coming in today....what?! How did they not know that. Also waited 4 hours for this neuro who ordered the EEG. This is off track...sorry.<br><br>
Has anyone been denied like this and have you had success fighting it? If so, how?? Thanks in advance.
 

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I have been denied like this. You need to have the neuro fight it for you. That is how it finally worked for us. So hopefully your neuro is not hard to get a hold of. But they ordered the test, and they had the responsibility to find out if it was going to be covered first, before the did the test. So it is now their responsibility to talk to the insurance company.
 

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Whoa! <img alt="" class="inlineimg" src="http://www.mothering.com/discussions/images/smilies/greensad.gif" style="border:0px solid;" title="greensad"><img alt="" class="inlineimg" src="http://www.mothering.com/discussions/images/smilies/angry.gif" style="border:0px solid;" title="angry"><img alt="" class="inlineimg" src="http://www.mothering.com/discussions/images/smilies/irked.gif" style="border:0px solid;" title="irked"><br><br>
Okay, do you need pre-authorizations to have proceedures done? Did the Doctor's office call and get the okie dokie to do the EEG?<br><br>
You can appeal the denial. DO NOT GIVE UP! That is exactly what the <img alt="" class="inlineimg" src="http://www.mothering.com/discussions/images/smilies/Cuss.gif" style="border:0px solid;" title="cuss"> insurance company wants you to do. You will need a letter from the Doctor to go directly to the Medical Director at the insurance company. Alot of times it is just the wording in the request that is wrong.<br><br>
Fight Mama! Don't let this <img alt="" class="inlineimg" src="http://www.mothering.com/discussions/images/smilies/Cuss.gif" style="border:0px solid;" title="cuss"> insurance company get you down.
 

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I have never paid a bill (that I wasn't supposed to). It could have been a simple coding error (had plenty of those!), it could be that the pre-approval wasn't filed correctly (had those too!), it could be that you just have to ask to speak with a case manager or supervisor and explain the reasoning behind the test. I've had bills denied for odd reasons (had an emergency bill denied because the dr didn't write on the form when the injury took place, he had stitches on his eye, does it matter when he cut it?? Apparently missing information means the claim is automatically sent to self-pay).<br><br>
I truly think that they just hope that you'll pay it. Which is stupid, but my experience suggests that. So many times it's just a simple phone call where I say "why did I receive a bill for this?" and 15 minutes later the bill is no longer mine.
 

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((HUGS)) Take a deep breath and call the insurance company. I have dealt with similar issues many many times and usually it is a stupid mistake that someone made somewhere along the line that is fairly easily corrected. Try not to get emotional on the phone, even when they transfer you for the billionth time. If you remain calm and cheerful, they are more likely to help you. If need be, get the neuro involved to fight for it. It can be done. If, for some reason the unsurance still refuses to pay, call the hospital billing to see if you would be eligible for any grants (sometimes people donate to the hospital to help pay the bills for people who fall under specific criteria) and/or if they would be willing to reduce the bill.<br><br>
Oh, and keep records of every phone call (get names and extention numbers) and piece of paper.<br><br>
I hope your son is doing OK. My daughter has epilepsy, so if you need an arm to lean on or a shoulder to cry on or an ear to listen, feel free to PM me.
 

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When you talk to your insurance company, you want to make sure you do two things: 1) have them send a copy of your policy, including the section which states why the coverage was denied; 2) ask them to send you a copy of the explanation of benefits as to why coverage was denied (if you don't have a copy); and 3) ask them what the appeal policy is.<br><br>
Under most insurance contracts, you must appeal a denied claim in a certain amount of time, or you lose the right to contest it any further.<br><br>
You should review the policy, including the section they say applies. They may or may not be right. Then send a written appeal which explains why you think they're wrong.<br><br>
Insurance companies are absolutely *(&$#(*&# crazy. I have a client with adult eosinophilic esophagitis who requires a protein formula. His insurance policy clearly states that his protein formula is covered at 100% by the policy. The insurer initially denied his claim because they deemed the formula to be "a prosthetic device." After a written appeal, they backed right down.<br><br>
You should also consider talking to an attorney. In many states, if a claim is wrongfully denied, the insured can claim attorneys' fees in addition to the money damages from the breach of the insurance contract. Many attorneys will take these claims on a contingency for that reason, so you won't have to pay anything up front.
 

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I once found out that I had a $27,000 balance at a home health company. The insurance company had denied most of our claims for almost a year. Since the HHC kept on sending them and getting denied, it kept it open. It took a couple of days of phone calls and a lot of stress, but eventually our insurance said they'd cover it 100% if we switched HHC. So we did, and they covered it. It was a huge pain in the butt though. It all had to do with a paper work snafu.
 

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Discussion Starter #8
Thank you ALL for your thoughtful responses. The neuro's office is going to appeal and we'll have to wait 30 days and go from there. We don't need prior authorization and I was told by the office they'd make sure it was covered. I am just going to hope their appeal works and I don't have to deal with it myself as I am really not up for that!
 
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