My dh had to have an emergency appendectomy about a month or so ago and we recently discovered that the hospital we went to was not on our provider list. Yikes! So, our already large deductible of $7,500 (private insurance - he had been laid off and was literally a couple of weeks away from being active with the insurance plan at his new job when this all happened!) will almost double now. We've been advised to send in a letter of appeal and I just had the idea that I should post here to see if anyone could give me any pointers on how to word the letter?

Basically, he had been having severe pain for a day or so and after vomiting and turning what appeared gray to me, I realized very quickly that we were not dealing with a normal flu or virus. It was getting late in the afternoon and we went to an urgent care office and after that, things just moved really fast because his white blood count was very high, very high blood pressure, etc. They didn't know what they were dealing with exactly and sent him to a hospital. We just never thought about going to one on our plan -- it was the last thing on our mind.

So, that's basically the story in a nutshell. Thought maybe some of you have worked in jobs where you were the ones making decisions on these kinds of things and what you would advise us to include in our letter, etc. Thanks! (And, any prayers would be appreciated -- that God would turn the hearts of these people to pay the bills as if the hospital was in the plan or, if that's not His will, that I will trust in His sovereignty and plan and promise that He'll provide for our needs).

what you said here is fine..it was an emergency situation and you just didn't think.

however if it says plainly on your insurance card that you have to have "preauthorization" or must use "in-network"..then i dont' know what they will do...I hope they give you sympathy! :)

I am not in insurance,

but i have seen a lot of insurance fights, and I advise to fight it, (crying might help ;) maybe even get srt

you can not pre authorize an emergency surgery that is absurd

your new hobby is to pester them until they give in,

at the insurance company, the low man on the totem poles job, is to save them money, (less then honorable companies count on you giving up)

make a lot of phone calls to your Ins company, talk to everyone you can, keep a list of phone numbers and names of who you talked to, find a sympathetic ear and keep talking to them until you get results (check on them every day)

they will pay if you don't let up(or at least negotiate the bill down) I have seen it happen several times!

if that doesn't work your new, new hobby will be to pester the hospital until they give you reduced fees or even forgive your bill all together, hospitals can and figure in that many patients can't pay, find a sympathetic ear there as well, keep records of who you talked to.

It may take some work on your part, but I know from others around me that you can get results.

good luck!

I do not work in the insurance field but I do deal with a lot of insurances. I write a lot of letters of medical necessity and I have helped with some appeals.

That said, it varies from insurance company to insurance company as to whether they will be sympathetic to your cause. Some are wonderful to deal with and others are a pain. Sometimes it is just the luck of the draw with who happens to process your claim that day.

I think the explanation you wrote here is good. I would follow-up with a phone call (or 2 or 3). I would ask to speak to supervisors if you don't get the response you are looking for.

Good luck!

""you can not pre authorize an emergency surgery that is absurd""

no, but...if you are at an urgent care, then you DO have a choice of which hospital to transfer to and continue care. and that is where the insurance company might stick you...because you had a choice at that point and didn't choose an in-network hospital. :(

I appreciate all the replies. When the doctor at the urgent care center finally came back in our room to advise us to go to the hospital, they were acting very serious and it just scared and shocked me and the last thing on our mind was if we should go to a hospital in-network. They wanted to send him by ambulance, but we asked if we could just drive instead. They made me promise that if we went to the ER room that we would be adamant that he be seen right away - then they even called the ER to let them know we were on the way. So, all of that combined with still, at that point, not knowing exactly what we were looking at, had us not thinking very straight.

Well, we'll see what happens.....a lady at the hospital advised that I should go ahead and get medical records from the urgent care center & the hospitals. Do you guys think I should go ahead and do that?

those records won't make much difference. I would not go to all that trouble before talking with the insurance company. If anything, they "might" want to look at the urgent care records to see if there was something which occurred there which "might" have limited where you went for treatment...make a call, say a prayer first...you might get a very nice person on the line and it might all go alot easier than you are anticipating.

Thanks, martinbeef....I think my phone call has already been made and the woman I spoke with was the one who informed me that I'd need to send a letter to the appeals department. I think I'll just go ahead and get that letter out in the next day or two. I'm not even sure if I'd be able to call during that waiting period. She made it sound like that we just need to send the letter in, they have 60 days to make a decision and didn't offer me any kind of phone number to call during that period. She was very kind and said she used to work in the appeals dept.....I wish she were still there because she sounded like someone who would have sympathized with our story.