How to lose your appeal rights, and how to keep them

Poor Mary.  She keeps running into unwanted out of network (OON) provider bills.  We first wrote about her (Mary and the Endocrinologist) in the June 24, 2015 edition of Health
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.  Now she has a $40,000 bill from an OON physician for a surgical procedure he performed.

Mary would have searched for another competent surgeon if she knew she would be responsible for the entire $40,000 surgery charge. But Mary did not understand the OON coverage provisions of her health plan; she believed that her financial responsibility would be no more than $5,000.  She also did not know that her health plan would reject the entire surgery claim.

Regardless of Mary’s contribution to the problem, her financial responsibility should have been no more than $20,000, as a soundly based and well-crafted health plan appeal should have produced $20,000 in health plan reimbursement.  But the surgeon’s office mangled her appeal, and her health plan upheld the original claim denial.

Why did Mary allow her surgeon’s office to file her appeal?  Actually, Mary did not give her consent voluntarily.  She was tricked into assigning her appeal rights to her surgeon.  While in the waiting room for her pre-surgery office appointment, Mary was asked to sign an authorization similar to this one that had the appearance of a straightforward consent to treatment and financial responsibility form.  She never saw Waldo hiding in line 3 of the Assignment of Benefits section.  How many of us would notice appeal language that is buried in a 500 word, small print document at a moment when all we can think about is our own health and well-being?  And how many of us would even imagine being in an appeal situation before the surgery had taken place?

The absence of an exit provision in the document Mary signed also is troublesome.  How could Mary have selected new appeal representation when she became aware that the surgeon’s office was not capable of producing a winning appeal?  Unfortunately, Mary had ceded her appeal rights to her surgeon, and her surgeon refused to relinquish these rights.

From the patient’s perspective, the business practices of most physicians we have encountered are open and understandable.  But beware of anyone who tries to hijack your appeal rights.  Here are some suggestions for preserving the contents of your bank account and control over your appeal rights:

  • If possible, avoid using OON physicians.  A professional health advocate with expertise in physician searches should be able to determine whether appropriate in-network physicians may be available.
  • If you think you want to use a particular OON surgeon, know (1) the amount you will be charged for the surgery; and (2) the OON benefits and coverage of your health plan before consenting to the procedure.  A health advocate with expertise in health plan matters should be able to help you estimate your potential out of pocket cost.
  • Request all documents that you will be asked to sign before your first visit with an OON physician.  You do not want to see these documents for the first time in the office waiting room.  A health advocate with expertise in OON provider matters should be able to review the documents, point out any problem areas, and as necessary, try to negotiate changes with the physician before you sign anything.
  • Do not be pushed into assigning your appeal rights to an OON physician.  Since most OON physicians require their patients to sign a statement agreeing to pay all charges not paid by insurance, there is no reason why an OON physician also should insist on representing you in a health plan appeal.  The physician already has what (s)he needs to compel payment.
  • If you believe you have been duped into assigning your appeal rights to an OON physician, a health advocate with expertise in health plan disputes and appeals should be able to provide you with an opinion of the likelihood of a successful appeal.  If there is a reasonable chance of success, ask your advocate or attorney to intervene with the physician to restore your control over your appeal rights.
  • Insist on a termination provision in arrangements with anyone who could be representing you in a health plan appeal.  You need the ability to replace the representative you selected if (s)he is not performing to your satisfaction.
  • Choose your appeal representative carefully.  Experience, instincts, and judgment are essential qualities of professionals who either produce winning appeals or know that an appeal cannot be won.  While there is no cookbook checklist for determining whether a candidate you are considering is competent, avoid anyone who agrees to represent you before reviewing your plan document and the claim denial.  And stay away from anyone who expresses optimism about a successful outcome in any matter involving OON services.  No OON case is an easy win.

Ceding appeal rights involuntarily is one of many potential landmines associated with using OON services.  If you are having a problem with an OON provider or think an issue could arise, please get in touch with us.  We will be glad to see if we can help.

Rick Pugach

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