Mother’s Story, Government Data Show Power In Appealing Denials

By Consumers For Quality Care, on October 26, 2018

When Diane Parnell’s youngest son, Brandon, woke up in the middle of the night complaining of severe abdomen pain for a third day in a row, she decided it was time to take him to the emergency room. Brandon’s older brother, Jamie, had spent 3 days in the hospital fighting sepsis, after his appendix had burst. Diane was fearful that Brandon might be suffering appendicitis too, Las Vegas Review- Journal reports.

Diane took Brandon to the ER at St. Rose Dominican Hospital, where she is employed. Blood tests and a CT scan found that Brandon was suffering from mesenteric lymphadenitis, also known as inflamed lymph nodes. He was prescribed antibiotics and recovered quickly.

But weeks later, Diane got another scare: a $21,377 charge for Brandon’s emergency room visit.

An explanation of benefits from her insurer, Health Plan of Nevada, a subsidiary of UnitedHealthcare, said Brandon’s pain wasn’t severe and therefore didn’t meet the standard for emergency care.

The ER visit was denied in full, despite the fact that Brandon’s physician said that he had seen appendicitis present with the symptoms he was exhibiting.

“It sounds absurd to me, and I work in health care,” said Parnell. “If you think it’s an emergency, you should be able to receive emergency treatment.”

Diane appealed the denial, both over the phone and in a written statement.

She won. Her insurer paid the hospital a bundled payment of about $4,000 and the doctors about $500 — five times less than the hospital billed her — and Parnell owed only her $75 co-pay.

A spokesperson for UnitedHealthcare said that they reversed their decision after receiving more information from the hospital.

Karen Pollitz, a private health insurance expert from Kaiser Family Foundation, said that many people don’t fight their insurance denials. Many more should, as data shows that denial appeals can be winnable. A 2011 Government Accountability Office report showed that appealed denials were overturned in 39 to 59 percent of cases.

If Diane had not appealed, she would have paid a rate 5 times higher than what her insurer ended up paying.

That’s because the insurer has bargaining power with hospitals and can negotiate rates closer to the actual cost of care. Individuals generally pay much more than the actual cost of the services, according to Pollitz. There is no federal law regulating such prices, which are set by hospitals based on their own criteria, and only one state, Maryland, has set caps on how much hospitals can charge, she said.

Pollitz recommends that when consumers receive a denial of coverage, they should take some time to understand their options before paying the bill.