“… The “dirty secret” of the insurance industry is that most denials can be successfully appealed…”
Gave it a go. Seems like it has potential. I’m still working through an appeal. My wife ended up in the ER in May and was directly admitted to the hospital for emergency surgery. Ten days afterwards we received a letter from the insurance company saying they had decided it wasn’t medically necessary so they wouldn’t be paying the $67k bill.
It has been a journey trying to get the appeal together. I had hoped the hospital would at least assist with a letter from one of the many physicians that attended her, but nope. We got laughed at by the surgeons office and told condescendingly "Yeah, that’s not how any of this works. "
My biggest concern from the AI generated appeals are being able to confirm the statements it is making isn’t just a LLM hallucination. As a lay person, much of the things necessary to make an argument are paywalled out of reach. For example, the insurance company cited the “2023 InterQual criteria for Surgical Conditions” as the reason why they are denying it. The AI appeal that was generated states that per the 2023 InterQual criteria for surgical conditions that hospitalization was medically necessary.
The only way it seems you can actually get access to InterQual is as a medical provider / payer.
… I thought most people actually just appealed most denials???
I was pretty sure this was already common knowledge?
90% of the time what happens is that you call up your insurance for some shit like hey my jaw be broken as fuck, and they go “nah thats cosmetic” and then you spend 2 weeks fighting with them until they cave and actually cover it.
you call up your insurance
They’re “solving” this problem with less agents or customer service staff, automating the process so you have a robot to deal with that doesn’t ever seem to understand what you’re saying, and can’t get you to the right place. Basically make it as hellish as possible to even get your issue reviewed. Then, they stone wall you and don’t take yes for an answer no matter what
In an ideal
worldcountry, we would have a different system, but we don’t live in an idealworldcountry, so what I’m shooting for here is incremental progress and making theworldcountry suck a little less,”.
It’s a good article. Don’t let that American exceptionalism creep into it.
my brother in christ, “in an ideal world” this string is a fucking turn of phrase.
The turn of phrase refers to things that are natural facts, human nature, stuff like that. This one isn’t any of those things, it’s weird to use it to refer to something specific to one country or place.
Yeah, honestly the appeal is a standard step in the bottom surgery process in the states. I know one lady who had to explain to her insurer why removal of the penis was a necessary step in her vaginoplasty.
“are you sure it needs to be removed? Have you considered just taking it off first?”
The insurance, probably
…This is just a network switch/router.
