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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.

Via CNN “The Chart

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