Does anyone have proven tactics or advice for appealing an insurance claim? I’m currently looking at a $32,000 bill from an emergency surgery I had in January to fix my shattered ankle and my United Healthcare insurance is being super shady and confusing about it.
It was out of network but I called before the surgery and got approval since I was 400 miles away from my network area (I live in San Luis Obispo, CA... was in same state though, in Davis, CA). I got a call 2 days before my surgery from the hospital saying that insurance wasn’t going to cover it. I called United again, got a different person on the phone, and explained that it was an emergency, I had already waited a week in between breaking it and my surgery date, they said since it was an emergency they would cover it as in-network. Didn’t get it in writing, just assumed they would keep their promise. I was super stressed out and in a lot of pain/on painkillers at the time.
Got the surgery, the bill was $59,000 originally but figured my insurance was going to cover most of it... then got a notice from the hospital that United had backtracked and instead of covering at in-network they had done some back-end thing to pay Medicare/Medi-Cal rates and I still owed $32,000.
I have a United Healthcare PPO, I called before my procedure, I’ve probably talked to like 10 different people from United since then and get a different answer every time. Finally got a notice that “it was processed correctly” so now I have to appeal.
Just looking for what info to include in my appeal letter... in terms of what I was told originally vs what they did, the fact that they did some kind of deal that doesn’t make any sense to me and isn’t outlined anywhere in my plan info to get to the amount they did, the fact that the $32,000 is more than I make in a year at my job, I don’t have any savings, don’t own any assets equal to that amount, just finished paying off my student loans, my credit isn’t good enough to get a new loan, etc?
Full story: I’m 29/female, and have had employer-paid healthcare with my job since I was 25, I was visiting my parents for Christmas and rolled my ankle carrying a load of laundry to my room, I had a plate and screws in my fibula from another break and surgery 8 years ago, and my fibula broke along all the screw locations, leaving my bone in 8 pieces. I also dislocated my ankle and fractured the bottom of my tibia, and all the tendons on the outside of my ankle had been completely ripped off of the bone and had to be sutured back on.
The break was really bad, basically snapped my fibula in half above the plate and there was no way of fixing it without surgery. They had to take out the old hardware and put in a new plate and screws among other things.
I’m also in the (at this point 4+ year) process of getting a diagnosis for hypermobility/joint issues, especially in my feet/ankles/knees/hips. This injury was absolutely a result of my unstable joints.
The hypermobility/possible EDS issues have been super stressful and frustrating and hard to find knowledgeable practitioners to help with. The surgeon they paired me with at Sutter Davis was amazing and knowledgeable about hypermobility and planned my surgery around that knowledge. I didn’t feel comfortable waiting longer to get the surgery and going back to SLO to possibly have someone less knowledgeable mess it up (SLO isn’t known for cutting-edge medical care).
Ultimately a lot of lessons learned but bottom line is I can’t afford what I’m being asked to pay and I’m extremely frustrated and just feel really dehumanized by my insurance company treating this like it’s not their problem. Any advice is appreciated!
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