How to Appeal a Denied Insurance Claim: A Patient’s Story of Advocacy

I thought I was having a heart attack. I had just given a talk about diabetes at a local college and was lugging all of the heavy stuff back to my car, which was parked ridiculously far away from the lecture hall. All while juggling an umbrella. Did I mention it was raining?

I felt a sudden sharp pain in my chest. My first thought was that I had strained a muscle. I unloaded everything into my car and started the 45-minute drive back home. The pain came back. My chest really hurt, and it would not stop. I tried calling my husband. No answer, of course. I heard a friend’s voice in the back of my head: Never mess with chest pain. Since I was in an unfamiliar part of town and love the mini-emergency room near my house, I decided to keep driving.

I arrived at the ER and, before I could say the name of my insurance company, I was in an exam room hooked up to various machines. They took blood. My troponin levels were elevated. Not good. Apparently, that happens when you’ve had a cardiac “event.” Keep in mind, this was a tiny stand-alone ER in front of a strip mall. The physician-in-charge started making arrangements to transport me – via ambulance – to a local hospital known for its cardiac unit.

I settled into a room just after dinner and learned I wouldn’t see the cardiologist until the next morning. This meant an overnight stay in the hospital. After a restless and noisy night, the cardiologist paid a visit. (What an odd coincidence that it was a doctor I had seen once back in 2017!) They ran tests. He was 95% sure I had a blockage in one of my arteries and needed a stent. They scheduled a catheterization procedure for the next morning. This meant another night in the hospital. 

Fortunately, while the cath uncovered a very minor problem, the doctor determined that I did not have a heart attack. I’ll never know why my troponin level was elevated and I had searing chest pain. Maybe it was stress, the doctor suggested. They sent me home. 

A few weeks later, a letter arrived from my insurance company. The hospital’s claim for $127,000 had been denied. That’s right, $127,000 for two nights in the hospital! Apparently, since I didn’t actually have a heart attack, the two-night hospitalization was deemed “not medically necessary.” And so I quickly had to figure out how to appeal a denied insurance claim.

I mentioned the insurance situation when I visited my PCP for a follow-up. She assured me the hospital would refile the paperwork and everything would be fine. “They always deny the first time,” she said casually. I wasn’t so sure.

A friend’s daughter, Fran, works for my insurance company. She offered to help me – off the clock, I might add. She told me to call the hospital first and ask them to check their coding and resubmit the claim. Fran also coached me about the magic words I should use if I ended up having to file an appeal.

It took a few months to get everything worked out, but the hospital fixed the codes and resubmitted the claim. I ended up paying only a tiny fraction of the giant bill. Deductibles and coinsurance, you know.

But what if I hadn’t had Fran? 

Enter Nayya Claims Advocate. I recently learned about this AI-based tool that helps people learn how to appeal a denied insurance claim. You upload a denial letter, and it writes an appeal for you, including citations from the medical literature that bolster your case. If you don’t have a “Fran” but do have a denial to appeal, you might want to check it out.

The bottom line in all of this is that when you live with diabetes or any other chronic condition, you need to ABA – Always Be Advocating. And part of that means knowing how to appeal a denied insurance claim so you don’t get stuck with bills you shouldn’t have to pay. One of the best ways to learn to advocate for yourself is to hang out with other people who face the same challenges you do. You can listen to what they did to solve a problem and adapt that solution to your particular situation. Peer support, like that offered by DiabetesSisters, provides a safe space to discuss your challenges, including how to become better at self-advocacy in its many forms.

Sign up for a support group meetup today.