Appealing A Claim Claims It’s Own Rewards

We are all used to receiving an Explanation of Benefit’s (EOB’s) that lets us know we are being denied benefits and/or payments.  Unfortunately, this is all too common in the health insurance industry.  And many times, the carriers are justified in their denial based on the way the claim was submitted by the provider.  Examples may be claims with CPT codes that are incorrectly submitted or backup information not properly justifying the claim itself.  But do not get me wrong, I am not letting carriers off the hook – because I believe that a “code”, or “notes on paper”, should never simply determine if a claim is denied or approved.  There are human circumstances, or a pulse as I like to call it, behind each claim that introduce factors which must also be considered. 

The following story is one of these situations: 

On the morning of March 31, 2019, while at Stratton Mountain Vermont, after experiencing a few days of discomfort, my client had awoken to classic symptoms of a heart attack, with left-side chest pains and arm numbness.  Due to his cardiac history and knowledge of an untreated blockage in his heart, he felt this situation warranted immediate care. 

With Hospitals at least 45 minutes away, an Urgent Care facility, located at the base of the ski resort, was the best option available at the time of this emergency. He was treated promptly, and it was determined that he had active chest pain and his blood pressure was severely elevated.  As the claims submitted to the carrier show, the medical providers at the facility performed an EKG and administered drugs to address his current circumstances.  All in line with what an ER staff would have administered.

The carrier originally denied the claim because the medical coding was based on an emergency treated at a non-participating urgent care facility.  If the member had gone to an emergency room this would be a moot point.  As we appealed this visit, we requested the carrier review the attached notes of the visit from the Urgent Care Facility when reconsidering this claim.  From our perspective, his decision to go to the nearest place, which had the ability to determine his situation, took precedence over any other action.

The appeal was promptly overturned, and the claim was paid in full, minus his Emergency Room Copay.  The medical director was afforded an opportunity to understand the overall nature of the members’ circumstances of that morning and realized that he responded in the most appropriate way for medical care.  Characteristics of the “human” element in this emergency required assessment. This was not something a code, or notes on a piece of paper, would have evaluated properly when processing these claims from the Urgent Care Facility.   

In general, carriers are forced to recognize initial appeals internally and, if the member is still unsatisfied, the claim must then be reviewed externally before a final decision is rendered.  The point here is, do not let a denial discourage your belief that an EOB is the final word.  Just like anything else, if you know you did the right thing, fight to uphold that decision – it can be worth a bit of extra time and effort!  As important, it will force carriers to recognize their members have a pulse to reckon with.