Protect yourself against health insurance reversal
Joan Gagliardi was liable for $1.2 million when her insurance comany reversed its approval for her treatment.
December 9th, 2011
02:03 PM ET

Protect yourself against health insurance reversal

In 2008, Joan Gagliardi was diagnosed with a rare autoimmune disease that caused scarring on internal organs, including her windpipe. It began to choke off her ability to breathe, but doctors at the University of Miami Hospital kept the damage in check with a treatment known as IVIG: Infusions of immunoglobulin.

The bad news came in 2010, when Gagliardi learned that her insurance company, Highmark Blue Shield of Pennsylvania, which had previously approved the expensive treatments, had reversed itself. The denial was retroactive, leaving Gagliardi liable for $1.2 million or approximately $50,000 for each infusion.

Fortunately for Gagliardi, the hospital didn’t press its claim, choosing instead to negotiate with Highmark. This year they settled up, with Highmark agreeing to pay $382,229. Gagliardi was off the hook.

Surprisingly, it’s not uncommon for an insurer to reverse itself, even after a claim is paid. State laws vary, but companies often take up to a year to perform “utilization reviews,” in which they re-examine claims that they’ve already processed.

In some cases, decisions can be reversed - leaving patients holding the bag - even years later.

“For example, if you have 2 health plans - yours and your spouse’s - and the one that should have paid second actually paid first, they will go back and reverse their payments years later,” explains Jennifer Jaff, Executive Director of group called Advocacy for Patients with Chronic Illness. “It’s a huge nightmare for consumers, but it happens. “

If an insurer denies your claim either before or after treatment, you do have the right to appeal: It’s guaranteed, under the health care law that president Obama signed in March, 2010. Of course a guarantee of appeal is no guarantee that the appeal will be successful.

Fortunately, there are things you can do to minimize your risk:

1) Make sure you're pre-approved. Unless you’re in the midst of an emergency, talk to your doctor to make sure any treatment - especially an expensive one - is pre-approved. That means your doctor has talked with your insurance company in advance, and received a promise that the treatment will be paid for.

2) Get help. Your doctor, hospital business office or employee benefits office can be a lot more powerful in making an appeal than you are alone. You can also get help from non-profit groups like Advocacy for Patients with Chronic Illness, or the Patient Advocate Foundation.

3) Be persistent. "You may go through three or four levels of appeals before you get a favorable resolution," says Nancy Davenport-Ennis, co-founder of the Patient Advocate Foundation.

4) Use the right words. Certain words will trigger a denial. For example, sometimes insurance companies refuse to pay for surgeries related to cleft lip or palate, saying it's not medically necessary. When parents appeal saying the child needs the surgery for "cosmetic" reasons or to "enhance esteem," the appeal often fails, according to cleftAdvocate, a group that works with families. Appeals that mention problems with "biting," "chewing," or "swallowing" are more likely to work.

5) You may need a lawyer. If all else fails, there are attorneys who specialize in insurance cases.

It’s worth saying, not all insurance denials are unreasonable. Coverage guidelines “are created by physicians who assess medical evidence, medical outcomes and overall health benefits to patients,” says Aaron Bilger, a spokesman for Highmark. “It’s to protect you.”

Dr. Christine Savage, who treated Joan Gagliardi, says the IVIG treatments kept her patient off a respirator. After a break of several months, Gagliardi began another round of IVIG in October. This time, Highmark said it would pay for 6 months, then evaluate whether it makes sense to continue.

Gagliardi says Savage and her team say they’ll do whatever it takes.

“We’ll just keep fighting the fight, to make sure I’m able to live as normal a life as possible with a progressive illness.”

For more on Joan Gagliardi's experience, watch “Sanjay Gupta, M.D." at 7:30 a.m. ET Saturday and Sunday.

soundoff (158 Responses)
  1. erection injection medication

    how to adminiter transurethral alprostadil muse video https://alprostadildrugs.com/ alprostadil cost per dose

    April 26, 2021 at 08:53 | Report abuse | Reply
  2. priligy

    dapoxetine hydrochloride priligy pills usa

    April 30, 2021 at 03:18 | Report abuse | Reply
  3. Frederic Cring

    That is a great tip particularly to those fresh to the blogosphere. Brief but very precise info… Appreciate your sharing this one. A must read article!


    May 4, 2021 at 23:06 | Report abuse | Reply
  4. buy aralen online uk

    chloroquinr https://chloroquineorigin.com/ sulfur effects on body

    May 9, 2021 at 02:27 | Report abuse | Reply
  5. avana

    buy avanafil canada avanafil

    May 15, 2021 at 09:33 | Report abuse | Reply
  6. combigan

    combigan eye drops generic buy brimonidine online

    May 15, 2021 at 19:05 | Report abuse | Reply
  7. tausAffessy

    tadalafil goodrx https://tadalafilol.com/ – tadalafil liquid tadalafil order online no prescription buy generic cialis online with mastercard https://tadacipetadalafil.com/

    May 23, 2021 at 14:01 | Report abuse | Reply
  8. Tritreviewifind

    cheap cialis pills for sale what is tadalafil prescription tadalafil online cialis without prescription https://tadalafilol.com/ – tadalafil without a doctor prescription

    May 24, 2021 at 09:51 | Report abuse | Reply
  9. brimonidine

    combigan generic prices brimonidine use

    May 24, 2021 at 18:18 | Report abuse | Reply
  10. cyclomune

    buy cyclomune uk buy cyclomune uk

    May 25, 2021 at 03:48 | Report abuse | Reply
  11. Soosteemocush

    https://apcalisetadalafil.com/ generic cialis online fast shipping https://tadacipetadalafil.com/ – cialis without a prescription tadalafil price walmart

    May 25, 2021 at 08:13 | Report abuse | Reply
  12. Tritreviewifind

    tadalafil daily online https://tadalafilww.com/ – tadalafil goodrx lowest price cialis cialis tadalafil tadalafil daily online

    May 25, 2021 at 13:00 | Report abuse | Reply
  13. tausAffessy

    side effects for tadalafil https://cttadalafil.com/ – where to get tadalafil prescription tadalafil online tadalafil price walmart tadalafil liquid

    May 25, 2021 at 20:27 | Report abuse | Reply
  14. tausAffessy

    cost tadalafil generic https://cttadalafil.com/ – cheapest tadalafil cost tadalafil generic generic cialis online fast shipping https://tadacipetadalafil.com/

    May 26, 2021 at 15:15 | Report abuse | Reply
  15. Tritreviewifind

    side effects for tadalafil tadalafil cost walmart tadalafil generic where to buy prescription tadalafil online https://tadalafilww.com/

    May 26, 2021 at 18:55 | Report abuse | Reply
  16. https://shiatsu-web.com

    Best view i have ever seen !


    May 26, 2021 at 23:29 | Report abuse | Reply
  17. https://shiatsu-web.com

    Best view i have ever seen !


    June 3, 2021 at 10:31 | Report abuse | Reply
  18. xF4o4Ukx0fmbO4

    94274 940600Normally I do not read post on blogs, but I wish to say that this write-up quite forced me to try and do so! Your writing style has been surprised me. Thanks, quite good post. 667783

    June 7, 2021 at 03:15 | Report abuse | Reply
  19. javascript development

    585651 495781Hi there, I identified your blog via Google whilst searching for first aid for a heart attack and your post looks extremely interesting for me. 41997

    June 15, 2021 at 05:54 | Report abuse | Reply
  20. www.pharmaceptica.com

    erectile restoration centers llc https://pharmaceptica.com/

    June 20, 2021 at 23:26 | Report abuse | Reply
  21. pharmaceptica

    how to get sildenafil cheapest https://www.pharmaceptica.com/

    June 23, 2021 at 19:55 | Report abuse | Reply
  22. Libbie Benderman

    Great articles. Thank you for the information learning street spanish


    June 25, 2021 at 12:55 | Report abuse | Reply
  23. www.pharmaceptica.com

    chloroquine and plaquenil https://www.pharmaceptica.com/

    June 28, 2021 at 07:08 | Report abuse | Reply
  24. where to buy delta 8

    Looking forward to reading more. Great blog post.Really thank you!


    June 30, 2021 at 00:18 | Report abuse | Reply
  25. pharmacepticacom

    discount erectile dysfunction https://pharmaceptica.com/

    June 30, 2021 at 05:23 | Report abuse | Reply
  26. Patrick Bombaci

    I am also commenting to make you understand what a amazing experience my cousin's girl undergone reading through your webblog. She figured out such a lot of pieces, including how it is like to have a great coaching heart to make other people clearly fully grasp chosen very confusing issues. You undoubtedly exceeded our own desires. I appreciate you for offering those helpful, healthy, revealing as well as cool thoughts on your topic to Gloria.


    January 21, 2022 at 05:52 | Report abuse | Reply
  27. Delpha Anthon

    I was reading some of your blog posts on this website and I think this website is very informative ! Continue posting .


    May 13, 2022 at 07:03 | Report abuse | Reply
1 2 3

Post a comment


CNN welcomes a lively and courteous discussion as long as you follow the Rules of Conduct set forth in our Terms of Service. Comments are not pre-screened before they post. You agree that anything you post may be used, along with your name and profile picture, in accordance with our Privacy Policy and the license you have granted pursuant to our Terms of Service.

About this blog

Get a behind-the-scenes look at the latest stories from CNN Chief Medical Correspondent, Dr. Sanjay Gupta, Senior Medical Correspondent Elizabeth Cohen and the CNN Medical Unit producers. They'll share news and views on health and medical trends - info that will help you take better care of yourself and the people you love.