I’m dealing with insurance claim denials. The claims are for aquatic therapy appointments and athletic training appointments over the span of six months, and all of the claims have been denied. My provider appealed the denials and successfully, and now the balance for these appointments is my responsibility
Because these appointments happened during the same span of time, my insurance company thinks that the aquatic therapy and Athletic Training were provided by the same practitioner. They were not. They were two different therapies provided for two different referrals with different diagnoses. I think this might be because my provider appealed all of the claims simultaneously, rather than separating out the aquatic therapy from the athletic training claims. I’m not sure, though, because neither my provider nor my insurance company are willing to give me copies of their correspondence outside of claims and appeal resolution letters.
My insurance company claims (no pun intended) that the practitioner providing the care is not licensed. I am 99% sure that both practitioners are licensed because they work for the biggest hospital system in my area. Also, the Athletic Trainer is listed as licensed on the hospital website, and he told me that he is licensed. I’m trying to see if I can get a copy of his license. I don’t have the contact information for The aquatic therapists to be able to ask for copies of their licenses… I actually saw a few different aquatic therapists depending on my scheduling needs.
My question is… How do I go about making sure that my insurance does not deny The next time I appeal? It should be a simple question of providing a copy of the licenses, or the information on the licenses for the insurance company to look up, and proving that the person who owns that license was the person who provided the therapy. But I don’t know enough about insurance or the healthcare system or how hospitals work to know how to prove something like that. And neither my provider nor the insurance company will allow me to talk to anyone outside of customer service reps, so I can’t get The inside scoop about how they came to the decision to deny the claims and the appeal. How did the insurance company come to the conclusion that the athletic trainer and aquatic therapist(s) were not licensed when they actually are? I feel like I have to catch their mistake so I can call them out on it and get the denials appealed. But I can’t do that if I can’t get additional information about the appeal. How do I get copies of the correspondence between my provider and my insurance company regarding these claims outside of EOBs? I have already looked through all of the EOBs and I’m not seeing any information about how they arrived at the conclusion that the practitioners were not licensed.
I’m also wondering how I can prove that the aquatic therapy was provided by a different practitioner than the Athletic therapy.
I suspect that my plan might not cover athletic therapy, but in my situation it’s kind of unclear. the athletic training that I received was actually a manual therapy called Graston. According to my policy, manual therapy is covered. And there’s no mention of athletic training being covered or not being covered in the policy
Another question I have is should I file a complaint through the office of consumer health insurance for my state? Or should I wait to do that until I have more information about the denials or after I have unsuccessfully appealed The denials several times?
Would it be helpful to see a lawyer about this? What type of law would that fall into? And how much would seeing that type of lawyer cost?
Right now I’m on the hook for between two and $3000, maybe more. Appealing the denial is a top priority for me, and I’m trying to figure out if I’ll be successful appealing this on my own or if I need back up.
Many thanks to the hivemind for your thoughts!
submitted by /u/Gloomy_Noise
[link] [comments]I’m dealing with insurance claim denials. The claims are for aquatic therapy appointments and athletic training appointments over the span of six months, and all of the claims have been denied. My provider appealed the denials and successfully, and now the balance for these appointments is my responsibility Because these appointments happened during the same span of time, my insurance company thinks that the aquatic therapy and Athletic Training were provided by the same practitioner. They were not. They were two different therapies provided for two different referrals with different diagnoses. I think this might be because my provider appealed all of the claims simultaneously, rather than separating out the aquatic therapy from the athletic training claims. I’m not sure, though, because neither my provider nor my insurance company are willing to give me copies of their correspondence outside of claims and appeal resolution letters. My insurance company claims (no pun intended) that the practitioner providing the care is not licensed. I am 99% sure that both practitioners are licensed because they work for the biggest hospital system in my area. Also, the Athletic Trainer is listed as licensed on the hospital website, and he told me that he is licensed. I’m trying to see if I can get a copy of his license. I don’t have the contact information for The aquatic therapists to be able to ask for copies of their licenses… I actually saw a few different aquatic therapists depending on my scheduling needs. My question is… How do I go about making sure that my insurance does not deny The next time I appeal? It should be a simple question of providing a copy of the licenses, or the information on the licenses for the insurance company to look up, and proving that the person who owns that license was the person who provided the therapy. But I don’t know enough about insurance or the healthcare system or how hospitals work to know how to prove something like that. And neither my provider nor the insurance company will allow me to talk to anyone outside of customer service reps, so I can’t get The inside scoop about how they came to the decision to deny the claims and the appeal. How did the insurance company come to the conclusion that the athletic trainer and aquatic therapist(s) were not licensed when they actually are? I feel like I have to catch their mistake so I can call them out on it and get the denials appealed. But I can’t do that if I can’t get additional information about the appeal. How do I get copies of the correspondence between my provider and my insurance company regarding these claims outside of EOBs? I have already looked through all of the EOBs and I’m not seeing any information about how they arrived at the conclusion that the practitioners were not licensed. I’m also wondering how I can prove that the aquatic therapy was provided by a different practitioner than the Athletic therapy. I suspect that my plan might not cover athletic therapy, but in my situation it’s kind of unclear. the athletic training that I received was actually a manual therapy called Graston. According to my policy, manual therapy is covered. And there’s no mention of athletic training being covered or not being covered in the policy Another question I have is should I file a complaint through the office of consumer health insurance for my state? Or should I wait to do that until I have more information about the denials or after I have unsuccessfully appealed The denials several times? Would it be helpful to see a lawyer about this? What type of law would that fall into? And how much would seeing that type of lawyer cost? Right now I’m on the hook for between two and $3000, maybe more. Appealing the denial is a top priority for me, and I’m trying to figure out if I’ll be successful appealing this on my own or if I need back up. Many thanks to the hivemind for your thoughts! submitted by /u/Gloomy_Noise [link] [comments]Read Morer/HealthInsurance