Any tips on how to successfully appeal an insurance denial?

Posted by pjebp @pjebp, Sep 16 4:21pm

I have been denied twice now from my insurance company to get my care at Mayo. I am applying for the final time. If it is denied again, what is the next step? Has anyone experienced something similar? What happened?

@pjebp, Mayo Clinic has some tips on this website.
– Helpful hints for insurance claims appeals https://www.mayoclinic.org/patient-visitor-guide/billing-insurance/insurance/post-service-denials/helpful-hints-for-insurance-claims-appeals

@2011panc @jomama @fireguy8891 may have additional tips and advice.
I really hope the third time is a charm.

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Ugh! As if having cancer wasn’t enough of a struggle, insurance and financial toxicity have to join in the fun. In what experience I have with this, it depends on what kind of cancer you have, what kind of insurance you have and any prior doctors or treatments you have had. Can I ask what kind of insurance you have? Did your doctor do the referral or self referral?

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@auntieoakley

Ugh! As if having cancer wasn’t enough of a struggle, insurance and financial toxicity have to join in the fun. In what experience I have with this, it depends on what kind of cancer you have, what kind of insurance you have and any prior doctors or treatments you have had. Can I ask what kind of insurance you have? Did your doctor do the referral or self referral?

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Also is the source you are seeking included in your insurance's network? You may want to see if your source for your treatment may have a program for curtailing some of the cost for your treatment.

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And some still believe we don't need UNIVERSAL HEATH CARE, it boggles my mind. It sounds like either Mayo doesn't accept your ins, or Mayo is out of network for your ins…either way your probably SOL. Why are you being denied?

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Would be helpful to know why you were denied. If you purchased your insurance from an insurance agent or broker contact them for advice.
If you are covered by a group health plan contact the HR dept. for help or have them refer you to the agent, broker, or consultant that sold the policy to the organization where you work. Please let all of us know what happens as insurance companies sometimes issue denials for various reasons, not just your situation with Mayo, and knowing what steps you take and the result of your appeal may be helpful to others who are facing a denial. And Colleen gave you good information. Best wishes.

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@waterboy

And some still believe we don't need UNIVERSAL HEATH CARE, it boggles my mind. It sounds like either Mayo doesn't accept your ins, or Mayo is out of network for your ins…either way your probably SOL. Why are you being denied?

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Not even Medicaid or Medicare gives the patient carte blanche medical treatment. Under both of those government management medical plans, one still may be denied reimbursement for medical treatment.

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@kenc

Not even Medicaid or Medicare gives the patient carte blanche medical treatment. Under both of those government management medical plans, one still may be denied reimbursement for medical treatment.

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exactly part of my point UNIVERSAL HEALTH CARE would/could solve this, but you would have to control the greed of capitalism and their lobbyists.

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When my pet scan was denied, my dr. Did a peer review call with the insurance co, and they then approved it. Cost me $4000 instead of 25,000.

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Hi there. What kind of insurance do you have? Is Mayo clinic in network with your insurance or out of network? I have worked with insurance authorizations in the past. If there's a referring doctor, you could have them do a peer to peer review with the insurance. If you could provide a bit more info on why you are seeking treatment at Mayo, what insurance you have, if you have a referring doctor, and has there been a peer to peer review done with supporting documents, I might be able to help.
Take care!
Kerry

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Thanks everyone I've learned a lot along this journey. I have much more to tell and I will get it written up and posted as soon as I can. The bottom line is that we appealed the final time to the IRO in the state in which we reside. We just learned this morning that the IRO overturned the denial! Next step is my radiation treatment and surgery.

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@pjebp

Thanks everyone I've learned a lot along this journey. I have much more to tell and I will get it written up and posted as soon as I can. The bottom line is that we appealed the final time to the IRO in the state in which we reside. We just learned this morning that the IRO overturned the denial! Next step is my radiation treatment and surgery.

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Jubilation, PJ! I look forward to hearing the details. When do you start radiation?

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It’s hard to hoot woo hoo! for someone needing cancer treatment. Lol truly I am so happy for you. Can’t wait to hear more.

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