By ARTHUR VIDRO
By Arthur Vidro
Last week’s column told how my free annual physical this year ended up far from free.
Despite laborious research and phone calls, I couldn’t get the hospital and my insurance provider to talk to each other about the matter. So I ended up paying the hospital money that should have come from the health insurer.
It’s far easier to challenge a fee in a store, where you can command a manager or proprietor’s attention and not be placed on interminable hold.
Still, fighting back is just about the only tool we consumers have available, especially when confronting faceless entities like insurance companies.
Although I lost the fight on my not-so-free physical, sometimes fighting back leads to victory.
Back in 2014, I experienced breathing problems. A general doctor advised me to see a lung specialist.
Since I live in Claremont, and Valley Regional Hospital is in Claremont, I made the appointment with the hospital’s sole pulmonary specialist at the time, a nice guy named Mahler.
I had no problem meeting and following up with Dr. Mahler, and am glad I went to him for however many visits it was. But I almost stopped after the first visit. Why?
Because the bill arrived. I stared at it in dismay. It was far, far, far more expensive than I had anticipated.
And all of it had to be paid by me.
Why? Because good old Dr. Mahler wasn’t part of my insurance plan.
I felt like I had a reasonable case to make, so I fought back.
When an insurance company rules on your medical treatment, and tells you how much they’re paying (in this case, nothing at all) and how much you have to pay (in this case, the whole thing), the insurer is legally bound to provide a means for appealing its decision.
Appeals seldom succeed.
To succeed, the protest must be valid. And it helps if the protest is polite and well-written. If your protest is written in “text” language, where most words are missing letters, and baffling acronyms predominate, and punctuation doesn’t seem to exist, well, don’t expect it to succeed.
I suppose it can be done via e-mail, but I wrote a real letter to Anthem Blue Cross/Blue Shield, appealing their denial of coverage for my pulmonary testing.
I pointed out that Valley Regional was the only hospital in the county, and Dr. Mahler was the only pulmonary specialist practicing in the county. I pointed out that if coverage was denied, then I and perhaps dozens or hundreds of others would forgo pulmonary treatment, because there would be no conveniently local option for obtaining such treatment.
I probably also pointed out that the two nearest hospitals beyond Valley Regional are over the state border, in Vermont, and thus excluded from my New Hampshire-only insurance coverage.
I still have the response, dated May 19, 2015, from Amber St. Peter, a grievances and appeals analyst. Here’s the third paragraph:
“After a review of the available information pertaining to this issue, I have made the decision to overturn the initial denial of benefits for the services in question. Specifically, Dr. Mahler had a retroactive network change and is in your health plan’s network. Please be assured I have forwarded your claim for an in-network adjustment.”
There was far more wordage, of the gobbledygook variety, but that was the gist of it.
Surprisingly, the appeal had succeeded. Better yet, it didn’t help just me, but helped others too. Anthem Blue Cross decided to retroactively place Mahler into its network of approved physicians for certain plans. And the unmanageable bill I owed the hospital would be paid mostly by Anthem – though I still had to chip in a hefty enough percentage of the amount due.
And I was able to make some return visits to the kind doctor as well, knowing he would be judged as in-network.
The good news is, sometimes a consumer can fight back and win.
The bad news is, it’s still up to the consumer to fight back.
And remember, an appeal cannot succeed if it isn’t filed in the first place.
Arthur Vidro is one of The Eagle Times’ recurring financial columnists. His “EQMM Goes to College” appeared in the May/June 2021 issue of Ellery Queen’s Mystery Magazine.
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