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Law Educator, Esq.
Law Educator, Esq., Attorney
Category: Legal
Satisfied Customers: 88327
Experience:  JA Mentor -Attorney Labor/employment, corporate, sports law, admiralty/maritime and civil rights law
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Medical insurance denied claim

Resolved Question:

On a recent trip to Las Vegas, my wife was taken to a Nevada Hospital for chest pains. They admitted her for cardiac testing and 24 hr. observation. This done probably because she is currently being treated by a cardiologist here at home in Virginia for past issues involving her heart. The hospital determined no heart issues and discharged her about 26 hrs later. Our insurance company refuses to pay the $24,000.00 and advised me to begin the 3 tier level of appeal. 1. have the Nevada Dr. call them for a Peer to Peer review of my wife's condition and to change the paperwork from inpatient to outpatient status. (The admin.supervisor already told me that it is against the law to do so.) The Nevada Dr. has not responded and the insurance company advised me to continue appeal the insurance denial decision. This has not been going well and it looks like we are going to get stuck paying this amount. The insurance companies 3 tiers of appeals look like they will take months to get through. We will probably be served by a collection agency by then and I really don't want to deal with collection on any level. If it does go into collection, I searched similar situations on the internet and looked into our options. 1. Virginia will let the collection agency garnish her meager wages to 25% of disposable cash. 2. The collection agency can also put a lien on the house, which is in her name. 3. The collection agency can take money from our joint bank account. I'm getting ready for the storm and want to know how to batten down the hatches, so to speak. We can try to make a payment arrangement with the hospital, but we are on a fixed income and can't afford more than $30.00 per month. I know the hospital billing office will talk about arranging payment, but will probably not go for that amount. I think they will negotiate for a lesser amount, but will want that amount up front. There is a good chance they will simply turn it over to collection agency if they can't get a significant amount from us soon. Personally, I think the fault lies with the insurance company by denying a claim for emergency treatment and finding some technicality to get out of paying this bill. They have already asked us (not in writing of course) to have a medical doctor change hospital records from inpatient to outpatient. They have put us on a coarse to appeal which will probably not avoid the collection agency getting involved. When they looked at the medications my wife was on, they rightly put her on cardiac ward and under observation, which is reasonable under the circumstances. PLease advise me (including any law under the Obama Act) as to how to make the insurance company pay their bills and not try to wiggle out of this.

Submitted: 1 year ago.
Category: Legal
Expert:  Law Educator, Esq. replied 1 year ago.
Thank you for your question. I look forward to working with you to provide you the information you are seeking.

First of all, regardless of how long the appeals process appears that it will take you, I am afraid you need to follow it for legal purposes. You have to file your appeal and you need to send a letter to the hospital administration that their doctor is refusing to cooperate with the insurance appeal and if your benefits are denied for their doctor's refusal to cooperate with the insurance appeal, then the hospital would be in breach of contract and you would not owe any bills due because the lack of cooperation on their part is the cause of the non-payment and the legal theory of equitable estoppel prevents them from benefiting from something that they caused.

The way to make the insurance company pay the bills is to follow their appeals process whether you like it or not. Once they have denied all three levels of appeal, then you can sue the insurance company as well for breach of contract. The "Obama Act" has nothing to do in the 7000 pages with making insurance companies pay in these situations I am afraid. Thus, you need to follow the appeal process and put the hospital on notice of their duty to cooperate and pursue the insurer through the appeals.

If the hospital tries to sue, which is the only way for them to do all of the things you have mentioned above and you can prove that the reason they were not paid was because of their own fault and as such their suit should be denied and that is how you stop them from getting a judgment against you and that is the reason for your letter to the hospital to lay the basis for you arguing the hospital has not been paid through their own fault and not your fault.


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Law Educator, Esq., Attorney
Category: Legal
Satisfied Customers: 88327
Experience: JA Mentor -Attorney Labor/employment, corporate, sports law, admiralty/maritime and civil rights law
Law Educator, Esq. and 19 other Legal Specialists are ready to help you
Customer: replied 1 year ago.

We have been in touch with the hospital and are still waiting for their doctor to comply with our request for a peer to peer between him and Anthem staff doctor. We called hospital billing dept. and they are not billing yet. The appeal is still in tier 1 and moving forward. I don't expect Anthem will pay because their letter stated my wife's condition comes under MCG (TM) formerly Milliman Care Guideline (R) stating the hospital can watch her overnight for chest pain complaint, but cannot admit her to a full stay. This can only be done here at her home, or in her doctor's office. My wife is under cardiologist care taking prescribed metoprolol and atorvastatin. This is probably why the ER physicians treated her case as they did. They also said, without the test they had to give her, she should not fly back home to Virginia for risk of heart attack due to effect of airplane. I suppose I need to get a lawyer, but it comforts me to know that we can ask you questions up until that time. Thanks for being there. I will definitely be in touch with more questions as this thing proceeds.

Expert:  Law Educator, Esq. replied 1 year ago.
Thank you for your update.

Anthem and their office quack paper pushers (who are mainly nurses who cannot get jobs anywhere else and all they do is read papers) are not qualified to overrule the treating doctor's medical opinion. You need to get yourself a letter from the doctor describing in detail the reasons for the stay and submit that with your appeal. You do not need an attorney right now at this point, but if they deny the tier 1 appeal, then you need to consider hiring a local attorney for pursuing the further appeal with them.
Law Educator, Esq., Attorney
Category: Legal
Satisfied Customers: 88327
Experience: JA Mentor -Attorney Labor/employment, corporate, sports law, admiralty/maritime and civil rights law
Law Educator, Esq. and 19 other Legal Specialists are ready to help you

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