Obamacare: when the plan says no, what to do

M husband had surgery last September.  There was a $40,000 charge for the surgeon’s assistant.  We never received a bill for this so were not aware of it.  She is not in network and the claim was denied.  Looking back through my records we did receive a letter from the plan saying the claim for the assistant was denied but we thought it referred to a $300 office visit which we had already resolved.  There were no details on the letter except for the date of service (day of the surgery) which I did not notice unfortunately when I first read the claim denial.  The insurer gives me 180 days to appeal but I did not catch the claim until 183 days after receiving a call yesterday from the surgeon’s collection department.  I express mailed the appeal the next morning (Day 184) and it won’t arrive until day 186!  Does this mean they will deny my claim because it was six days late?

Confused in Illinois

Dear Confused in Illinois,

Under health reform, the insurer has to offer you three levels of appeals.  There are two levels of internal review, plus an independent external review.  Here are the details about the required appeal process.  The most important thing that you need for this review is a detailed statement from the surgeon about why the PA was necessary.  

You have a tough situation, since the insurer can technically point to the 180-day deadline and refuse to hear any further appeals.  The state of Illinois has a bureau to help you.  Go to Illinois Department of Insurance page and file a request for assistance.  

While you pursue the appeals and assistance, you should tell the surgeon what has occurred.  The surgeon does bear some responsibility for this, since he or she did not provide the plan with adequate records to justify the PA.  The surgeon’s filing of the claim (and follow-up data) has a longer time frame than your 180 days for appeals.  Generally, providers have 12 months from the date of the service to file a claim. So, you may have another avenue to fix the problem this way.

Good luck!

Linda Riddell

About Linda Riddell

A published author and health policy analyst with 25 years’ experience, Linda Riddell's goal is to alleviate the widespread ailment of not knowing what your health plan can do for you.