Incident
An employee of an Emry client was facing a major health battle and was focused on getting healthy – not on whether their cancer specialist was in or out of network. Unfortunately, an out-of-network surgeon was used for their major cancer surgery and the resulting cost was $37,200.00. The insurance provider erroneously processed the claim as in-network, resulting in a reimbursement of only $3,000.00 to the provider. As a result, the employee received an upsetting balance bill from the provider for $34,200.
Resolution
The Emry CareCost team performed a thorough review of the claim, the explanation of benefits, and the full medical report where we uncovered that the treatment was incorrectly processed. Our experts re-submitted the claim to the insurance provider to correct the error. This claim resubmission resulted in an additional out-of-network payment of $9,000.00 – but still leaving the employee on the hook for $25,200. To secure additional coverage for this claim, the Emry team had to file 2 appeals which demonstrated that the surgery was very complicated, required a full medical team, and took 8 hours to complete which proved the breadth and life-saving nature of surgery.
Success
The first appeal was denied. But the Emry team filed a second appeal which resulted in an additional payment of $28,200.00 as the deductible and out-of-pocket maximum were reached. As a result, insurance covered 100% of the surgery and the employee saved $34,200.
