What do you think this means? Insurance question.

IBackBevo

Anyone know anything about insurance appeals? So I've been appealing testing related to IF for the past 7 months or so...and, yes, this testing was done over 1.5 years ago. I am now at the point that the appeal is at the benefits office. I emailed and asked the person assigned to my case what the status was as they told me it would 1-2 weeks and it has been a month. She wrote me back and said that she had feedback from her medical director (who is a physician) regarding my appeal and was in the process of reviewing it with her supervisor and team. She said she should have a determination within the next few days. I thought the physician/medical director made the decision? Why would she need to review? Can anyone shed any light on this? I know we have at least one person who is in insurance on here...

imoverit

I dont have an answer but I wish you the best of news in the next coming days.

amandaleigh1

I did an appeal once and when the decision came back it looks like a panel of physicians had been assembled to decide on the appeal. At the time I thought that they were independent of the insurance company to make it less biased, though I have no evidence of this. I win the appeal, so I was pleased.

IBackBevo

Thanks for the responses. I guess every company is different.  I exhausted appeals with the insurance company and now I am at the stage where the employer's benefit office (it is an employer provided plan) is reviewing the appeal.  I think that if I lose here, I then get an outside appeal. 

The thing that I found weird is that I was given the impression ahead of time by this same person that the "medical director" would make the final decision, but the way this most recent email reads it sounds as if that is not the case.  This is the first time an actual physician has looked at the appeal so I feel like that our chances are better.  The lady who reviewed the claim before with the insurance company did not even know the difference between an HSG and Hysterscopy.  When I asked for the documents she based her denial on, she sent me documents related to my hysteroscopy and highlighted a bunch of notes related to the hysteroscopy...I wasn't even appealing the hysterscopy, I was appealing the HSG!  When I questioned her about why she sent me docs about the Hysterscopy (which was not even being appealed), it was clear she thought the hysterscopy and HSG were the same procedure. SMH.