I Won An Insurance Appeal Today: A Great Day

I am very excited because I just received the best news for a client.  We won an external appeal.  It reversed a potential $150,000.00 hospital/doctor/rehab bill.  What a day!  The insurance, Humana, has to pay.

This journey started when I received a call asking me if I could help  with an appeal.   Sara was frantic because Humana without contacting them, had denied payment for her husband’s hospitalization and providers. She was now receiving bills.  The cost was over $100,000.  She didn’t understand what had happened.  She told me her story.

After years of being in a group plan from her husband’s employer, they were switching to an indvidual/family plan with the same insurance, Humana.  She had contacted Humana sales in October 2012, applied on the phone and received confirmation of acceptance to begin 12/1/2012.  She had given all the medical history for both of them which appeared in the copy of the application.

Towards the middle of November, her husband was not feeling well and saw his PCP.  He was referred for a variety of tests including a stress test.  Results were suspicious but he kept getting referred for more tests.  Each time he needed a test, Sara would diligently contact Humana to get prior approval.  She told me over and over again  with every call, she would tell the representative the plan was changing 12/1 and were they OK.  Consistently, she was told there was no problem.

The final test was November 30 and appointment with the specialist on 12/3.  She iterated to me, that never were they told a diagnosis.  Not once did the doctors indicate there may be a major change in health status until 12/3.  From that appointment, her husband was admitted directly to the hospital for cardiac surgery.

In February, Sara began to receive the bills. She contacted Humana and was stunned to learn payment was being denied because of a pre existing condition.  Humana stated the new symptoms were not reported, and as per their policy, any new symptoms or diagnosis two years prior to the policy not reported are considered a pre existing condition and not covered.

What should she do?   They wanted to appeal but needed help.  I said I would help organize and write the appeal.  I explained there were to two types of appeals, internal and external.  The first step was to do an internal appeal.  With this appeal, we submit information and letter to Humana and ask them to reverse the denial.  If that doesn’t work, then we try the external appeal.  This appeal is reviewed by an outside organization.  In many states, the reviewer is the  Department of Insurance, as it was in Sara’s state.

I told Sara, appeals are a roll of the dice.  There is no quarantee of a reversal and hardly any logic to decisions.  My job is to put forth the best evidence  as to why the reversal is required. I need to provide undeniable proof that Humana has made a mistake.  I also told her that it will take time and we need to be patient and thorough.

What was going to be my premise to reverse this decision and how could I prove it?  There were two questions; was this a pre existing condition and had Sara, acting in good faith, tried to get clarification from Humana on what to do.

My clients were amazing in getting information to me.  I requested a copy of the application, the policy, medical records, timelines, dates of phone calls if available and letters from the doctors. They had all this information to me in 48 hours.  It made my job much easier.  

My review of the application showed no problems.  In fact, the precursor for any heart disease, hyperlipidemia, was noted.  There was no indication that my clients had hid anything. I gathered research that showed hyperlipidemia and cholesterol are causes of heart disease.  I  reviewed the policy clause on pre existing condtions.  The doctors notes never indicated a definitive diagnosis until the 12/3.  I examined the timeline which included Thanksgiving weekend and the final test on the last friday afternoon of the month.  

I had asked my clients to get from Humana copies of all their interactions.  Most people don’t realize that everything is either recorded or documented and it is your right to get copies.  Humana, actually sent copies of the recordings to my client.  That would have been great except no one could open them.  I tried every program I knew, sent it off to my whiz copmuter tech who sent it to his colleagues and no one could get it.  I put it aside because time was ticking.

My approach was two fold.  First, was this really a pre existing condition if there were already indications of heart disease as stated on the application. Second, my client had made efforts to let Humana know of her concern about the change in policy.  As with all my appeals, I provide with my letter as much pertinent documentation as I gather.  I noted and documented the number of calls my client had made to  Humana.  My client would say to me, “Does Humana think I called just to shoot the breeze and find out how their day was going?”  It made me laugh everytime.

My final step was to have a colleague review and edit the letter.  I sent it.  Humana won’t let you fax  or call to follow up.  It makes me think I am sending it into the black hole.  Why these departments are walled off from consumers makes no sense to me.

Denied.  That was the response from Humana.  The letter appeared to be an attempt at how they tried desperately to help but couldn’t.  They referenced two phone calls and stated Sara had never asked or discussed the change in policy. My clients were devasted and scared.  Their lives were on hold and the fear of bankruptcy was looming.  They couldn’t understand what they had done wrong.

I was not surprised by Humana because why would they reverse a decision to pay out so much money.  I told my clients to remember, this was an in house review by a Humana employee who had to focus on the corporation.  We would go for the external appeal.  I explained in their state, there is one internal appeal allowed and then it goe to the external group which was the Department of Insurance.  What I didn’t tell them was, their state had a low per centage of reversals in external appeals for issues regarding pre existing condtions.

My job was to take what was in the denial letter and fine tune our points against Humanas.  My major premise was the phone calls.  I argued that Humana had acted in bad faith by not directing Sara to the appropriate customer service department to answer her questions.  In her state, bad faith issues fall under tort law and are resolved in courts.  I knew that would not be addressed by the external appeal decision but it might open a door.  

I sent the letter and waited.  About a month later, I received a call from the reviewer at the Department of Insurance.  The reviewer was asking me if I had any further copies of the phone calls.  I said I had copies of the voice  conversations but I hadn’t been able to open them.  It was hard for the reviewer to believe no one could open them and requested I  forward the copies which I did.  

I followed up several days later and the reviewer told me no one in her department had been able to open the calls.  Humana had been contacted and told to get usable copies to them.  I knew this would take some time.

Another three weeks passed and I emailed the reviewer.  I was informed, usable copies had been obtained.  After listening to the copies, further information was requested from Humana.  I saw that as a hopeful sign.  I knew the reviewer had found something that needed clarification.

Because I write the appeals, I am the one who gets the determination.  I saw the envelope and ripped it open.  I actually was expecting a denial but there it was in bold letters, “The Department has reversed the denial.”  The denial was reversed for two reasons.  First, Humana had not provided my clients with instructions on how to contact them in event of any changes. Second, Sara made every attempt to let Humana know as indicated in the phone calls.  It was clear she thought she was informing them of the changes.

I immediately called my clients with this fantastic news.  Sara’s comment to me was “I have my life back.”

This appeal was a perfect storm.  My clients were engaged and timely in getting me information.  The reviewer was remarkable and exceptional in the analysis of this appeal.  I am good at knowing what goes into an appeal.  All this peieces worked for the benefit of my clients and a great outcome.

I don’t always win appeals.  This case reminded me  to always look for the smallest detail.  The fact that Humana had not given clear instructions to contact them, never occured to me.  My experience with other appeals has also been the smallest detail can reverse a denial.  My job is to hunt down the smallest detail and present it.  I don’t always know where to look but this case taught me the possibility exist and I need to find it.

Such a great day!