(InvestigateTV) — You pay your health insurance every month, expecting it’ll be there when you need it.
However, what happens when your claim is denied?
A Connecticut mother shared her story of insurance claim denials with our investigators.
Kelly Nielsen’s insurance company repeatedly denied coverage for her premature daughter’s specialized formula. Layla was born at three pounds and spent more than 50 days in the NICU before coming home on doctor’s orders to receive special neonatal formula.
“It was scary. It was regimented. I’m a first-time brand new mom, so I’m like, my God, what do I do? I just have this peanut of a baby,” Nielsen said.
Despite keeping all receipts and submitting a claim for around $600 worth of formula, Nielsen’s insurance company denied the claim multiple times over several months.
“The lady said you didn’t fill out the form right. You missed some doctor code number that the pediatrician knew,” Nielsen recalled of her frustrating experience with the appeals process.
The missing information was an NPI, or National Provider Identifier, a unique code that connects a claim with a doctor. Nielsen estimates she spent at least two days on the phone, sending emails, and filling out forms trying to resolve the issue.
“I think in total I was denied three or four times. And it’s like they make you do extra work that’s going to be wrong that you don’t know, so they don’t have to pay you and they don’t have to give their money away,” Nielsen said.
Kathy Holt, Connecticut’s acting health care advocate, says 65% of calls to her office involve denials, with 40% being medical necessity denials and 25% being administrative denials.
“It can be very complicated to fill out the forms. But what’s really important is to try to fill out as much information as possible to avoid getting the claim rejected,” Holt advised.
When contacted about Nielsen’s case, Anthem Blue Cross Blue Shield acknowledged the confusion and approved the claim for the formula, calling the situation a mistake and apologizing for the back-and-forth that resulted in no action being taken.
“That’s an entire month’s worth of groceries. That’s a car payment. That’s almost more than half of our mortgage. It’s our bills. It’s everything,” Nielsen said of the $600 reimbursement.
Read more of Kelly Nielsen’s story here.