The SECOND payment denial by the Insurance Company (IC) hovered like a dark cloud over my head. The new 60-day appeal filing period had just begun and the sense of urgency had not yet grabbed my attention. If the dark cloud meant rain, I felt like I could do a hippy hippy shake speed walk and still have time to find me an awning that would save me from being drenched. Of course I did not know how much money I was supposed to spring if I eventually lost the appeal. Maybe if I knew, I’d be flying! But paying for something that I shouldn’t is not an option. Failure to prevail is not an option.
Two weeks passed and I decided I had lived dangerously long enough. It was time to rattle Dr Brevity’s RN. I went on a messaging spree with the RN through the Patient’s Portal. Okay, that’s grossly exaggerated. I fired exactly 2 messages in a row over a span of 2 days. Exaggeration happens when the Patient/Blogger suddenly forgets her coolness and magnifies everything.
My first message read: I received IC’s Notice of SECOND denial of payment based on the information provided by you. I agree with you that your submittal was responsive to IC’s requirement to reverse the denial. Now the new and improved reason for denial was “When you enrolled in a Medicare Advantage Plan, you selected a Primary Care Physician to coordinate/authorize your medical care. The services received were not authorized and not payable by Monarch.” Please continue to represent me to Monarch.
I did not receive a response. I sent another message.
My second message read: Please let me know what action you intend to take. IC gave me another 60 days to appeal the SECOND denial. I don’t want to lose that opportunity.
I still did not receive a response. The following day, I gave up being Ms Nice Guy. I reached for the phone. After all sorts of mysterious phone connection motions at Club Med, RN and I finally found our voices.
RN: Celia what do you need?
Me: Did you get my messages at the Patient’s Portal?
RN: No I did not.
Me: The long and short is, I got a Notice of SECOND denial of payment. All I want to know is if your office intends to continue to represent me.
RN: We already gave IC what they needed.
Me: In other words, your office is through helping me.
RN: There’s nothing more we can do, but I can call Guardant and ask for Patient Claim Assistance.
While we were talking, she found my messages. She did not see them because she had not turned on her computer since her return from vacation.
Anyway, I thanked her for everything she had done to help me and proceeded to call the number that Guardant gave me if I needed help in filing the claim. The phone rang.
Voice on the other end: How can I help you?
Me: Please connect me to Client Services.
Voice: This is Client Services.
Me: Oh, you are Client Services. My contagious laughter roared.
Voice: (Laughing, from contamination). Yes I am.
Me: I need help to file a claim.
She asked for identification, date of birth, yada yada.
Voice: OK I found your case file. We received the same Notice that you received. I’m glad you called. But first I want you to know that win or lose the appeal, there is a fixed fee you must pay.
I felt my hackles kind of lift from the back of my neck.
Me: How much?
Voice: 60 dollars
Me: Come again please. I want to be sure you did not say 6K dollars.
Voice: 60 dollars
I laughed. And she laughed.
The appeal is supposed to be a lengthy process. I hope everybody lives long enough to see the end of it.
(to be continued)
Is there any experience out there like this? I’d appreciate input.