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Anyone had success fighting an insurance denial for back surgery?
Spine Health | Last Active: Sep 4 12:13pm | Replies (55)Comment receiving replies
Thank you for the reply. No, both neurosurgeons are in network. The nurse at my last visit said that it is very difficult to get any surgeries approved, much less than with a medicare advantage. I'm going to appeal the denial. Anyone have any recommendations?
Replies to "Thank you for the reply. No, both neurosurgeons are in network. The nurse at my last..."
From what I have seen other people experience if at all possible I would never leave my traditional Medicare / United Health Plan. I have seen people lose their life savings because they were somewhere not in network, surgeon wasn’t in network., advantage just didn’t cover . Hospitals also have problems with some Advantage plans, they say they will pay one amount then don’t. They say you need a prior authorization then take forever to get it for you. I honestly feel they definitely don’t have the patients best interest at heart. ❤️
1. Ask for the entire claims /appeals record. My understanding, as the patient you are entitled to all the correspondence.
2. Request/demand the NPI, name and credentials of the "decision-maker" at each stage.
The NPI is a unique identification number for covered health care providers.
https://www.cms.gov/regulations-and-guidance/administrative-simplification/nationalprovidentstand#:~:text=The%20National%20Provider%20Identifier%20(NPI,for%20covered%20health%20care%20providers
Often they have a standard "script" to deny claims, executed by non medical providers.
On appeal it is probably looked at by someone with a medical profession. It should ho to a neurosurgeon, preferably a board certified neurosurgeon, however insurance companies are notorious for not hiring qualified board certified specialists. Sabmves them money but could be a general medicine doc retired for 20 years filling out the denial.
I follow Kaiser Family Foundation news on the insurance issues, denials (I'm a geek that way)
Here's one apparently useful website to look at for further information
https://www.patientadvocate.org/explore-our-resources/insurance-denials-appeals/where-to-start-if-insurance-has-denied-your-service-and-will-not-pay/#:~:text=Reasons%20your%20insurance%20may%20not,requested%20under%20your%20health%20plan
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I called the Medicare rep at my plan directly and discussed it. She was very helpful (and probably as frustrated as we were by the denial.) The insurers are required to provide "plain language" instructions for appeal, and have quite short windows in which to respond.