State: Pennsylvania
Max out-of-pocket, deductible, copays all met; premiums have all been paid on time.
A health insurance had pre-authorized a non-acute in-patient stay at a mental health facility (covered benefit) for a patient that survived a suicide attempt after multiple acute, in-patient hospitalizations (acute, in-patient not effective for this case, as well as intensive outpatient done previously for multiple years but not adequate at this time). PPO plan, pay out-of-network provider first then seek insurance reimbursement, insurance (through this process) paid in full for some months. Patient is an autism spectrum disorder case and contraindicated to live with self or family due to nature of suicide attempt.
All of a sudden, the health insurance company retroactively denied claims from one month prior to that date WITHOUT even issuing a denial letter (sent a draft of a denial letter a few weeks after the alleged date of the denial), all while the patient was still in treatment. Asked for the denial letter many times; ignored request each time. They then (a month later) sent an internal appeal decision letter (internal appeal automatically conducted done due to member not being satisfied with outcome). The insurance company cited guidelines in their appeal decision letter (finding a way to highlight patient progress and calling it better enough to move on); they don’t even meet most of the guidelines they cited themselves, which they must meet all of for discharge according to their own guidelines.
The health, safety, and life of the patient is plausibly at risk if they are financially forced to leave, as they have been determined to be a non-acute risk to self to others (not safe for discharge).
Whole treatment team agrees medical necessity for patient to remain. Advice (please and thank you)?
submitted by /u/Recovering_Bird
[link] [comments]
State: Pennsylvania Max out-of-pocket, deductible, copays all met; premiums have all been paid on time. A health insurance had pre-authorized a non-acute in-patient stay at a mental health facility (covered benefit) for a patient that survived a suicide attempt after multiple acute, in-patient hospitalizations (acute, in-patient not effective for this case, as well as intensive outpatient done previously for multiple years but not adequate at this time). PPO plan, pay out-of-network provider first then seek insurance reimbursement, insurance (through this process) paid in full for some months. Patient is an autism spectrum disorder case and contraindicated to live with self or family due to nature of suicide attempt. All of a sudden, the health insurance company retroactively denied claims from one month prior to that date WITHOUT even issuing a denial letter (sent a draft of a denial letter a few weeks after the alleged date of the denial), all while the patient was still in treatment. Asked for the denial letter many times; ignored request each time. They then (a month later) sent an internal appeal decision letter (internal appeal automatically conducted done due to member not being satisfied with outcome). The insurance company cited guidelines in their appeal decision letter (finding a way to highlight patient progress and calling it better enough to move on); they don’t even meet most of the guidelines they cited themselves, which they must meet all of for discharge according to their own guidelines. The health, safety, and life of the patient is plausibly at risk if they are financially forced to leave, as they have been determined to be a non-acute risk to self to others (not safe for discharge). Whole treatment team agrees medical necessity for patient to remain. Advice (please and thank you)?
submitted by /u/Recovering_Bird [link] [comments]Read Morer/HealthInsurance