Morgan J Freeman: "Anthem Blue Shield Blue Cross -- just denied cancer follow-up MRI to check spread was deeme

[Ms. Toad]

51. Most of the time it doesn't even require a formal appeal.

I refuse to be shunted off to the appeal process until all direct avenues of informal appeal is exhausted. I just keep asking for supervisor after supervisor after supervisor until I get the straight story about the denial. Normally, it is something stupid that is easily fixed. A step therapy medication - where they lost the documentation that the first line meds had already been tried; coding errors - where an out-of-network care that had received in-network authorization was still being coded as out-of-network, etc. Those kinds of errors aren't really suited for appeal, since it takes actual conversations with real people to sort out what actually happened and resolve it. If it gets sent to appeal, without a conversation to sort it out, it just gets denied on the same basis as the original.

As to the coding error - it took 200 hours of my time, because every new claim on the approval number required calls to two corporate entities and convincing one of them to call the third to get the bill re-coded, the payment sucked back, and a new payment sent. I got to the point where I could walk the customer assistance agent through a computer system I had never seen - because in my prior conversations I learned exactly what was happening and why it was repeatedly mis-coded (the initial authorization or out-of-network care was for a second opinion only; it was converted to authorization for care - but instead of assigning a new number, they just tacked the new authorization pages into a long .pdf document under the original number, so the people doing the coding saw treatment - and only authorization for a second opinion because they didn't bother to scroll down in the .pdf). Ultimately, I insisted that they open a new number for the third go-round (multiple surgeries), and that solved the problem. Had I just appealed, that would never have happened. I probably would have gotten each bill resolved - at the cost of a ton of paperwork each and every time, and I never would have know that I needed to insist on a new case number being assigned. I have also successfully had an insurance company rewrite their nationwide software system because their software didn't match a kind of policy they sold.

If working informally doesn't work, then I appeal - I've probably done it only once or twice, and I'm far less successful at winning appeals than I am at working through customer service. By the time I file a formal appeal, it requires a doctor's cooperation (and the few who don't cooperate quickly become my ex-doctor).
Working through customer service, I've won every appeal I've chosen to fight. There were two out of perhaps 50 that I chose not to fight (small dollar amounts, not likely to be repeated).

But - yes - they count on us not challenging them, whether informally (as I do most of the time) or formally. Virtually no one challenges the system, so they win on those, and others give up too soon - so they win those by attrition.