As head of patient advocacy for CSI Pharmacy, Michelle Vogel spends much of her time jumping through hoops on behalf of patients to get insurance companies to pay for the essential services they need. She also wasn’t shy about advocating for herself when she was in the hospital last summer with COVID pneumonia.
Recently, however, Michelle got a bill for several thousand dollars from the hospital for services not covered by her health insurance plan during that episode, and it baffled her. She had already met her annual deductible and out-of-pocket maximum, so she expected all further charges to be covered.
When she reviewed the itemized statement, however, she could see that some of the charges for the nurse practitioner who oversaw her care were being denied by her insurance company. What she couldn’t understand was why the plan denied these charges on some days but not on others, even though the codes used to identify those services were identical. It didn’t make sense.
“I do appeals for a living, and I didn’t even know how to go after this one,” Michelle says. “How do you appeal something when you don’t really know why you’re being denied?”
Michelle spent hours on the phone with customer service representatives from both the hospital and the insurance company, trying to unravel these questions and to press her case for what she knew was right. But the insurance company insisted that the hospital had filed the claim with the wrong procedure code, and the hospital insisted that they had not made a mistake.
On top of it all, Michelle is a COVID long-hauler. More than six months later, she still has lingering shortness of breath, daily migraine headaches, severe fatigue, and stomach symptoms. Having to fight with the insurance company over a bill they should have paid to treat this disease was more than she could bear.
At one point, Michelle was ready to give in and just pay the bill. The hospital had reduced some of the charges, but she was still left on the hook for nearly $1,000 dollars that she thought should have been covered by insurance. But it was a lot of money, and she couldn’t just let it go.
“It was irking me to no end,” she says. “And I kept thinking, how many of our patients get bills like this. What do they do?”
What Michelle did was write letters to both the insurance company and the hospital. In these letters, she briefly told her personal story about how her mother unknowingly exposed her to COVID, how her mother died from the disease shortly after, and how Michelle spent nearly a week in the hospital struggling for her life.
She then explained what she understood about the insurance case and asked that her situation be reevaluated and the charges covered or dropped. In making her case, she included details—claim numbers, procedure codes, and charges she was being billed for—along with her understanding of what her insurance plan should have covered.
In the end, she was successful. Recently she received a notice from the insurance company saying the denial was overturned and they would cover the outstanding charges. It was a huge success for this patient advocate as well as a lesson in perseverance. Now, she says, she will write letters for everything.
“I always say appeal, appeal, appeal, and I wasn’t going to do it,” Michelle says. “I had to tell myself, listen to everything that you preach. You have to do this.”
Tips for writing a successful appeal letter:
- You will find the company’s phone number and mailing address on the back of your insurance card, on the Explanation of Benefits (EOB), or on the denial letter from the company.
- Include the patient’s name, the policy number, and the policy holder’s name.
- Be sure to include your own contact information.
- Write a concise, detailed note about why you think the charges were denied in error. Be sure to cite the terms of your insurance policy that apply to the situation.
- It helps to tell your own story, but keep it brief.
- Include a photocopy of any documents that will support your argument, including the EOB with details of the denial. If this is not possible, provide the date on the denial letter or EOB, what charges were denied and the provider who was supposed to be paid, and why (if you know) the charges were denied.
- Always keep dated notes, receipts, correspondence, and other documentation of your interactions with the insurance company and/or the hospital or provider.
- For insurance companies, check your EOB to find out the procedure for submitting an appeal, and be sure to follow these guidelines.
- Be a pest. Timeframes vary for each plan and provider, but if you haven’t heard back within about two weeks or the time frame specified in the EOB, call to be sure your materials have been received and show in their system.
CSI Pharmacy has patient advocates who can help you navigate this and other health insurance challenges. We offer this service regardless of whether or not you are a CSI Pharmacy patient. Drop us a line at [email protected].