Imagine needing emergency surgery at an in-network facility, only for insurance to deny your claim. Worst, they say the surgery was not a covered benefit, so you are left with the entire bill. Sadly, the hospital cannot appeal or fight this claim on your behalf, all they can try to do is collect the balance from you. In the end, either you must pay a big bill, or the hospital does not get paid for the life-saving service they provided you.
However, there is a better way. One that is both a positive patient experience and leads to payment on denied claims. Athos Health has created a new solution to help both individuals and healthcare providers when a claim is denied, and the individual is financially responsible. To demonstrate the value we create, we want to tell the story of Ryan Delaria.
Ryan is a long-haul truck driver by trade and insurance through his employer. During one of his deliveries in the spring of 2021, Ryan was struck with extreme stomach pain and noticed a bulge on his stomach. Ryan could not wait to finish his delivery, he was at a point where he needed immediate care, so he called his employer to seek guidance. His employer advised him to go to Legacy Mount Hood Medical Center a nearby in-network hospital. The emergency department quickly diagnosed him with multiple hernias that were causing a blockage of his small intestine. Due to the blockage, Ryan needed immediate surgery. The surgery was a success and after three nights in the hospital, he was able to fly home. Fortunately, Ryan has made a full recovery.
Weeks later, Ryan learned that the hospital stay was going to be denied when he received his explanation of benefits from UMR. “I was shocked when the hospital stay was denied by insurance, leaving me responsible for $57,276”
Ryan reached out to the hospital to see if they could help him fight the denied claim with his insurance company. He was informed that since insurance said he was responsible, Legacy was unable to help him appeal, and they were going to send him to collections if he did not pay within the next month. Ryan was on his own and did not know what to do. “A local law firm put me in touch with Athos where they were able to get the ball rolling and began to craft an appeal that specifically outlined my case and why this denial was unfair. Little did I know, being admitted to the hospital for a life-threatening emergency would leave me facing the most stressful bill of my life.”
Why would a hernia surgery at an in-network be denied? UMR did not dispute that the surgery was medically necessary. Given it was an emergency, Legacy was not required to obtain an authorization for surgery. In fact, he was told by UMR that the denial was due to the surgery being considered a non-covered benefit by his health plan. “I am not going to lie, I wanted to get a lawyer involved but my Athos Advocate told me to be patient and had the confidence that he could help me resolve this bill that would have likely sent me into bankruptcy. ”When Ryan’s advocate called UMR, he found that the denial was based on a prior surgery he had in 2015. Due to one of the diagnosis codes put on the claim by Legacy, UMR denied the claim believing it was related to the prior surgery. However, it clearly was not. The Athos Advocate collected the medical records from both surgeries, the plan documents, and Ryan’s background story. This information was used to clearly demonstrate that the procedure was a covered benefit and therefore should be covered by UMR.
Athos’ comprehensive patient advocacy program is designed to help people like Ryan navigate insurance denials leaving them financially responsible.
In the end, Athos was able to get the denial overturned and UMR paid Legacy $56,861. Based on Ryan’s financial situation, this is far more than Legacy would have received if they tried to collect from Ryan. Also, Ryan did not owe it, he was stuck in the middle. His story shows that an Athos Advocate can deliver a phenomenal patient experience and increase collections for healthcare providers.
From our experience, we have found patients have a separate set of rights and opportunities to overturn these denials that are distinct from your organizations. Our approach taps into these rights by partnering with the patient to solve the problem. Like Ryan’s case, we have been successful 55% of the time in overturning denials, taking the financial burden off the patient, and helping healthcare organizations collect for their services.
Athos will apply the same practices and concepts to help your organization appeal denials to increase collections while creating a better patient experience.
Contact us at firstname.lastname@example.org to learn how we can help your organization and click the link to explore our website. We are so confident in our results; our fees are fully contingent upon our success rate.
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