how to contest ins. co. claim denial

Discussion in 'Fibromyalgia Main Forum' started by simonedb, Nov 19, 2009.

  1. simonedb

    simonedb Member

    hey I had a private big ins. co. deny claim for redlabs/vip cfs complete panel (looking at rnase, natural killer cells etc) and it was orderd by a physician in large university clinic setting, so a mainstream respected setting. They delayed their decision by like 8 months and then called it "experimental" even though they had inexplicably paid for a cheaper genova lab test earlier in the year which would certainly be "experimental" by ins. co. standards too, its just a big bill they don't want to pay so they find loopholes. Any advice on how to appeal successfully?
  2. rockgor

    rockgor Well-Known Member

    you could appeal to the state insurance commission. Can't say w/
    any assurance that this will help.

    Doesn't sound like the kind of case that would interest an attorney. Don't
    know if small claims court would handle a case of this type or not.

    Good luck
    Rock
  3. dvdav2000

    dvdav2000 New Member

    I was at the 2009 Reno conf. VIP. ( form Red) was an exhibitor in the patient info area...they were a little wishy washy when I asked them on the status of their Medic r e #. Alot of private carriers will use that as the standard to pay. Redd had ceased for awhile....now VIP is set up for the XMRV opp. ( I think )
    Redd used to be the standard back in the early 2000's to do the RnaseL testing... basically you sent the blood, ans they shipped to Belgium if I recall... I may be wrong...

    Another lab is Immunosciences in Calif. was a lab that insurance paid for the CFIDS panel that tested for all the major levels and RnaseL, New Topic.. and I think the lab that was the base lab for the Montoya study, and some of the other studies is called " Focus " Labs... Quest bought them a few months ago... Whenever my Dr. specifies that my labs go to Focus they comply...

    dvdav
  4. justjanelle

    justjanelle New Member

    myself a few years ago -- they denied part of the surgery to correct a badly-broken boot (pins, plates and bone graft) saying it was to correct a flat-foot problem (which I didn't have!)

    Anyway, here's what I ultimately had to do. Keep in mind that this took a *long* time, and several letters back and forth.

    Make sure you keep copies of all your letters to and from them, and also notes (including names and dates) on any phone conversations you have with them.

    First, write a letter yourself to appeal the decision, stating as you have here that these tests are the standard tests given to patients with your symptoms/condition, that it was ordered by a qualified doctor in a respected hospital, and any other thing you can think of to support your claim that this was a standard diagnostic test and not experimental. (Do NOT mention that they did pay for that other test that was *more* experimental -- they will retroactively deny that one too!)

    They'll probably refuse you again.

    Then get a letter from the doctor stating why the procedure was "medically necessary", as descriptive as possible and naming the specific procedures needed and why (in your case the tests, as they might relate to your symptoms). You'll probably want to check over the letter and send it to the insurance company yourself, along with another letter of appeal. (Keep a copy of the physician's letter -- you'll probably need it.)

    If they still refuse it based on that, then you write them an angry letter repeating that the tests were medically necessary and not experimental in the least, referencing the physician's letter (include another copy). In this letter you should also state that if they continue to refuse to pay for this legitimate, medically-necessary test, then you will next take the issue to your State Insurance Commissioner.

    This will scare them, and will frequently shake the payment loose. It did in my case. If it doesn't in yours, then I guess you need to call the office of the State Insurance Commissioner and find out what to do to appeal to them. Then do it.

    The bad news is that this whole process will take literally months! And your lab bill will be hanging out there, with their billing office demanding payment. Talk to the billing manager and see if they will be willing to wait while you wrestle with the insurance company. They might. But they will probably want to to be paid by you instead. Try to get them to settle for you paying the insurance-allowed amount (which will be considerably less than they actually billed) and setting up a payment plan for it.

    This way you're covered, the bill isn't referred to collections, and you are making progress on paying it off in the event that you never do get the insurance company to pay up.

    A long exhausting process, but I hope it works for you!

    Best wishes,
    Janelle