YSK how to appeal health insurance denials
a month ago by certified_expert to c/youshouldknow
Well known health influencer explains how to fight back health insurance denials in United States.
- explains (in simyle terms) how insurance companies work.
- shows basic steps to create a solid appeal.
- recommends some online tools (AI based) to craft the appeals.
Land of the fee. Home of the [wage] slave.
"America" isn't the only country with these issues
My family emigrated from China... its about the same on the other side of the ocean... (honestly don't know what the "free healthcare in China" stuff came from... certaintly didn't apply to my family from Taishan with Taishan Hukou)
They're so used to this lol, they think this is just normal
Also: Young people are expected to fund their parents retirement... its a crime to just abandon your elderly parents who cannot afford their living (unless you have proof of abuse)
China is coming from extreme poverty and a feudal society until not that long ago, and is a different culture. USA is coming mostly from European culture, but is doing worse in this field than any European country, despite being far richer than most European countries.
China has made a lot of progress the past 50 years, conditions in China are now without comparison better now than they were 50 years ago. In USA conditions are in many ways worse for the average worker than they were 50 years ago.
honestly don’t know what the “free healthcare in China” stuff came from
I have no idea what you mean. AFAIK China does not have healthcare for all, or free healthcare. But apart from that IDK how healthcare actually works in China.
I have no idea what you mean. AFAIK China does not have healthcare for all, or free healthcare. But apart from that IDK how healthcare actually works in China.
Common rhetoric I get told in the Fediverse... I mean if you look in World News comms, you'll see those...
Which just confuses the fuck out of me since its a contradiction to my parents first-hand accounts (and also some of what gets told by my aunts (and other relatives/people in my parent's social circle in China))
I've never heard healthcare is free in China, but I have heard it is much much more affordable there. Again, I've never been, but that's not a hard bar to clear in comparison to the USA.
In the workplace you hopefully had help from your union. Americans rarely have that luxury.
Also it's only in USA that France might be considered communist, because that's completely moronic extreme right propaganda, since France has a free market economy like the rest of EU.
At least in EU insurance is under better regulation than in USA, but it still sucks to have to make insurance claims, that the insurance company has every interest in rejecting.
Unions at least know good lawyers but it wasn't necessary at all, the first denial was just to waste my time. Sadly union membership in France is becoming insignificant so they're not as good as they once were.
And I was saying France is “communist” in jest.
The regulation is all right in France but insurance definitely has some very favourable laws (many delays for notifying them are quite short to the point where with shortages of GPs you have to waste everyone's time at the ER if you really need to be off work).
I live in America, and healthcare is free in my country.
I think most countries in America have free State healthcare.
No you don't, you probably live in the Americas, huge difference. The language we use here is English, and unless you live in USA, you don't live in America by definition of how English works.
https://en.wikipedia.org/wiki/United_States
The United States of America (USA), also known as the United States (U.S.) or America
This is how the word America is used in English, completely disregarding whether you like it or not.
I would like to, politely, remind that America is a continent with more than 20 soveraign countries. (Many of those countries having a much better health system.)
The country in question, here, is United States of America, aka, USA.
I would like to, politely, remind that America is actually 2 continents.
Why you gotta insist on being annoyingly pedantic for no reason? You know when people say "America" when the discussion context is a country, that they are referring to the USA. And then being pedantic about it and wrong? Oh boy.
I was surprised when I started teaching internationally that there is no global consensus about the number of continents.
In South America, they consider America to be one continent. (Remember Bad Bunny's Superbowl performance when he listed all of the countries that make up America?)
Some countries say that Eurasia is one continent. Others say it's two.
Some countries do not consider Antarctica a continent because it doesn't have permanent inhabitants.
It's really not as black-and-white as your middle school geography textbook said it was.
You are presenting an ad hominem argument. Do you have anything actually meaningful to bring to the discussion other than your self-righteousness?
My argument is this:
First: America is named after the italian cartographer Amerigo Vispucci. He is attributed to be the first to realize America was not India, as Columbus thought. This happened long before the country even existed.
Second: The name of the country IS United States of America. The word "of" literally means that the group of states is in or belongs to America. Therefore, America cannot be the country itself.
Third: There are plenty of other examples of continents with geographical subdivisions:
- East Europe and Europe.
- South-east Asia and Asia.
- South Africa and Africa.
Indeed, there are different types of sub-divisions. For example in America:
- cultural/linguistic: latin- and anglo-america
- geographic: north-, central-, south-america. Some also consider the caribean as a same-level distinction.
None of these divisions create a new continent.
Fourth: The shorthand "american" was introduced by the french as a quick way to identify the two main variants of English (the language). They started to call the English from England "Anglais", and the one from this new continent "Anglais américain" or simply "américain".
Fifth: in a lighter tone... Would you trust the same country that defends this health "care" system, the imperial units system, and that elected this current president to tell you how to split the world?
You can see it as pedantic. I see it as respecting the 20+ countries that have to live with this name appropiation. We can of course disagree, but I invite you to bring actual arguments.
Do you have anything actually meaningful to bring to the discussion other than your self-righteousness?
I did in the first part of my comment. I didn't provide any links, because you didn't. If that's what you want though, fine.
https://en.wikipedia.org/wiki/Continent
The seven-continent model is taught in most English-speaking countries, including Australia, Canada, the United Kingdom, and the United States, and also in Bangladesh, China, India, Indonesia, Pakistan, the Philippines, Sri Lanka, Suriname, parts of Europe and Africa.
So together that represents 4.1 billion of the 8.3 billion people on the planet
The six-continent combined-Eurasia model is mostly used in Russia and some parts of Eastern Europe.
If we add just Russia to that list, even ignoring the rest of Eastern Europe, we come to 4.2 billion, or over half of the global population now.
The six-continent combined-America model is taught in Greece and many Romance-speaking countries—including Latin America.
I'm assuming you're in Latin America, and that's why you're taking this personally. My commentary was simply about you being pedantic about something that doesn't really matter. The tone of your post seemed to imply that your opinion here was the only correct one... something that clearly isn't accurate.
I didn't realize that half the world combined the Americas, much like it seems you didn't know that as well given your original post.
Either way, this discussion is off topic from the original post about Healthcare in the US and ultimately pointless here. I can only assume you came here looking for an argument given the tone of your original post and responses so far, so you can have fun arguing with yourself over pointless delineations that serve no purpose. Have a good day.
No USA has hijacked that. What you are talking about is the Americas plural with an S, which include north, south and central America.
I absolutely agree with you that it is stupid and arrogant of USA to call itself America. But it is shorthand for United States of America.
In my own language Danish "Amerika" is indeed the 3 Americas combined, but in English "America" is used interchangeably with USA.
https://en.wikipedia.org/wiki/United_States
The United States of America (USA), also known as the United States (U.S.) or America,
https://da.wikipedia.org/wiki/Amerika
Amerika er den samlede landmasse indeholdende Nordamerika (inklusive Mellemamerika) og Sydamerika
Translation: "Amerika" is the combined landmass containing North America (including Central America) and South America.
It depends on the language, and here we use English. And yes I agree with you it is stupid. But people from USA are called Americans, hence it is sometimes more logical to use America than USA.
https://en.wikipedia.org/wiki/American
American, something of, from, or related to the United States of America, commonly known as the "United States" or "America"
I don't know what your native language is, but you are probably transferring norms from your own language to English, that in this context makes you simply wrong.
US self recognizes as "United States of America". That is what themselves wrote in their constitution. Check my other comment.
It is not a culture transfer what I'm trying to do. It is simple logic and historical facts. The taxonomy used by usaians, yankies, "estadounidenses" (some current and past proposals) simply makes no sense, in any language.
Now you simply have to piss off and stop being stupid. I have shown you 3 sources documenting that you are wrong, and explained how and why.
And no it has nothing to do with simple logic, because that is not how language is defined. Language is defined by how it is used, and everybody uses it the way I described to you.
If you persist being stubbornly ignorant, I will just have to block you. I tried to give you a thorough explanation, responding with this bullshit afterwards is simply not worth my time.
You cannot define languages no matter how stupid or illogical you think it is.
No. We absolutely should not know how to do this. Because our elected officials should be working to curb Insurance Corporations and Corporat abuse and fraud in the most general sen..... Oh wtf am I talking about. Just hoping when I get sick its a fast death
The new American Dream
1000% agree with you. But this is the old dilema of being idealistic vs being practical:
Yes, there is abuse and it is horrendous. Yes, the system must be changed. But if you are ill, right now, you shouldn't try to change the system, you should try to get better. And even when it is sad to have to resort to these tactics. It is practical to use them, given the current state of affairs.
I know someone who works for a major insurance company in the US, in the appeals department. I don't know the intimate details of everything about their job, but one thing I always remembered is if you have an expedited appeal (for a medical emergency), and they're requesting documents that you don't send within the 72 hour deadline an expedited appeal has, the denial gets an automatic administrative overturn - the appeal is approved. Presumably for liability reasons, combined with that the company gets fined if an expedited appeal takes over 72 hours to process. Potentially a usable strategy if you have an expedited appeal that's weak enough to have a chance of the denial being upheld in the end, and they're also requesting documents. Probably a pretty rare combination of factors though.
But I've also been told by them that most denials end up being overturned on appeal in the end. And that they see people appealing denials on a daily basis, where they were denied the absolute stupidest reasons - people who obviously should never have been denied in the first place. Hard to say if this means most denials are bullshit, or if it just means people only bother trying to appeal the most obviously bullshit ones.
In any case, it is just companies just dragging the process to make people tired and hopeless...
That on itself is pure evil: to mentally abuse people already in mental distress and potentially fighting for their lives.
I once owed $1100 for bloodwork a teledoc ordered. I had a wellness exam and they ordered a bunch of bloodwork which I got done at a major well known national lab. My insurance said the claim is out of network and refused to pay on some of the bloodwork orders.
Although my teledoc was licensed to practice medicine in my home state, my insurance plan stated it is billed for the providers primary state. In that state, my insurance plan is not contracted with the lab that it's contracted in my state.
I’m going to assume it says that we shouldn’t use ‘the Mangione method’.
Yeah... it is basically a practical guide to fight within the current (evil) system.
Definitely something nobody should need to do in a civilized society.
insurances
I think mass nouns do not work like that.
thanks! Fixed
I work in pharmacy, and what I see between prescription prices and insurance adjudication processes... it's a fucking eugenics program, plain and simple. I feel awful for people who need insulin and adhd medication in particular.
Throw ****** ********* at the ***** of these corporate overlords, located at ************ or searchable through ***************
[redacted]
That's awesome! Where are you from? Could you please share a bit about how things work where you live?
I pay somewhere around €500 a month in health insurance. This insurance is mandatory, the payment depends on income, is free for people who cannot afford it, and covers my whole family.
Co-pays are minimal: €5 for prescribed medication, €10 per day in hospital. Some stuff cost extra, if you want something beyond basic services. I pay e.g. for better fillings (non-amalgan) at the dentist, 50-80€. Dentures and such are pricy, but there are extra insurances you can buy for that.
The copays sound super reasonable. Based on the currency, I assume it is Europe. May we know which country?
I worked for a non-profit insurance company, (Fidelis Care,) that was purchased by a for profit conglomerate, (Centene.) Health insurance companies deny appropriately billed and coded shit all day long hoping:
- you don't know your rights
- you can't figure out how to submit appeals if you are smart enough to know your rights
- you will give up because the process is too complex, can take as much effort as a full time job, and can lower your credit rating while you wait for the appeals process to pay out.
I witnessed appropriately coded claims get improperly denied all day long. I spent most of my time working there helping people file appeals, or giving them the information to the state agency where they could file external appeals after our own review team denied their internal appeal.
Right before covid hit, a gentleman was approved for pain injections, but couldn’t get into the office before his authorization ran out, because anything non emergent was closed. Once the doctor’s office was open, the doctor submitted a new request, with the same clinical information, and it was denied. I put an appeal together for this man, painstakingly pulling the clinical records from the first authorization, the second authorization, EVERY PAID CLAIM related to his condition, AND EVERY RX CLAIM FOR PAIN MEDS the company paid for to demonstrate medical necessity. 4 hours of work. The appeals team denied it in 15 minutes later, it was absolutely not reviewed. This is the straw that broke the camel's back and made me rage quit Fidelis.
Holy shit... whoever decides "this is how it works" has to slowly burn in hell. The average Joe simply cannot imagine, let alone comprehend, the level of evil that these allegedly "people" can pull out...
Link to Article?
It's a youtube video. I don't think there is a written article
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If you read the above headline without thinking it's insane, chances are you are American.
No developed country is as insane as USA, not even close, not even remotely close.
If you are sick, you shouldn't need to fight for treatment, only in a sick society is that necessary.
save