Denial of Care

By Jane Arnoff Logsdon, MSSA, LSW 

I consider myself a pretty savvy and resourceful consumer. I know how to solve problems that come up in the day to day situations we all face. I have navigated my way through more than a few complicated and sensitive financial situations.  Add to that my ability to be persistent and you would think that I could figure out a simple denial of an insurance claim with ease, right? In this case, the answer is no.

Here’s the situation: my husband decided to quit smoking after many years of puffing away by using a smoking cessation program. I assumed that our medical insurance would cover the program and did not bother to check on this before he went to his appointments.  According to their web site and the literature, they support smoking cessation and even offered free nicotine patches to members. Our medical facility had paved the way for supporting smoking cessation efforts on the part of their employees and patients. So, needless to say I was very surprised to receive a bill from the provider as well as an explanation of benefits stating that the claim was denied. I tried to put my frustration aside in order to solve the problem. I appealed the claim online and felt pretty confident that the appeal would be granted. After a few successful clicks, I sat back and waited for the good news.

Instead, I received a five page, single spaced document instructing me (I think) about how to further appeal the claim. After undertaking the dizzying task of trying to decipher this document, I contacted the Nurse Practitioner at the smoking cessation program to ask for her help with the denial. After some research on her end, she told me that she thought that the nature of the billing or perhaps the specific coding caused the denial. In the last conversation, she said that she would do a little more research and get back to me on how to pursue the denial.

As for the insurance company, a helpful but mildly perplexed representative asked me to go back to the provider to find out how the claim was billed. I spent another few minutes reviewing the mega document, hoping it would explain itself. No such luck. After days of waiting, the Nurse Practitioner did not return my call. Eventually, after some more hair pulling and fretting, I decided to give up.

I do feel a little sheepish in telling this story, as if I should have known better or been more prepared. However, I did learn some good lessons from the experience that I can share with others and make sure they don’t make the same mistake. First of all,don’t assume a service is covered by insurance no matter what your plan.  Insurance companies have very detailed benefits documents- you need to review all the details.  Next, make sure to assess any services and related charges you receive during the visit- they all will appear on the bill. Finally, take advantage of covered preventative care that the insurance company covers.  It is important to maintain your health and prevent major issues later on down the line.  During my experience, it seemed that all the players in this game were at least a little confused.  I came away from this experience feeling humbled, wiser and with a lot to pass along to others to help prevent them from falling victim as I did.

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Jane Arnoff Logsdon, MSSA, LSW is the Volunteer Coordinator with NAMI Greater Cleveland and was a contestant in the 2012 Costs of Care Essay Contest.