Help finding out details from the hospital regarding a current appeal with insurance

In December I had a family member go to the ER due to extreme pain but also a loss of ability to use their legs to walk. After attempts to get the pain under control and in order to determine the reason for the loss of mobility, they admitted them. The hospital decided to charge for the stay in two claims (this is important later) – the first three days then the next 4 after that, during which the pain was brought under control and several MRIs and tests were conducted to determine the cause for the loss of mobility, which returned in one leg, but not the other. No clear cause was found. Eventually, we were sent by the hospital to an inpatient rehabilitation unit where we stayed for 2 more weeks to attempt aggressive physical and occupational therapy to at least get to the point where we could go home in late December.

Now for the odd part. Insurance has paid for the first part of the hospital stay, and the stay in the rehabilitation unit, but there is a current dispute with the second part of the hospital stay. Here's the timeline as I understand it:

It was initially denied at the end of December as something not approved, and my insurance requested additional information from the hospital. The hospital made attempts to adjust several items and provide more information (clinical notes and patient profile) and did so by the end of March The decision on the claim in late April was a denial (code 397), medical/surgical advisor contacted but did not approve services/treatment An appeal was submitted by the provider on May 20th and my insurance informed them (and us) that the appeal is under medical director review as of May 24th with a compliance date of mid July.

This brings us to now. Obviously, as this is thousands of dollars, we're concerned we're going to be on the hook for this part of the stay. At no time during it were we told insurance had a problem. Additionally, approving the first part of these claims (the first three days of hospital stay) and the last part (the inpatient rehabilitation unit) makes not approving the middle part (the second part of the stay, during which pain control and additional tests were run to determine the mobility issue) puzzling. I can only assume insurance believes, in denying this part of the claims submitted, that they thought the hospital needed to make the call to send to the inpatient rehabilitation unit sooner, though the pain control and tests/MRIs extended well into the second part of the hospital stay in dispute so staying a bit longer looked to be medically necessary.

My question is ultimately how to find out current specifics about this appeal, like what the hospital is saying to justify payout and what exactly they've submitted to our insurance for consideration. We're kinda stuck between two giants – a hospital and our insurance. The billing department at the hospital can't tell us anything since we haven't been billed yet, and my insurance provider's support agents don't have access to the specific details, only the general path of the claim as I outlined above. From here, where can we go to get more detail from the hospital? I hesitate to call the doctor on the claim as a team under them was handling the care, updates, and notes, and the hospital doesn't seem to have a direct number for case management.

I just want to have some peace of mind as I don't think we should be responsible for something that at least without further info, appears to be a back-end issue with how this part of the claim was submitted, and I don't want to wait until a decision before seeking more info – though if any of the professionals here have insight as to why this might be happening, even if it's in generalities, as obviously things are different on a case-by-case basis, I'd be glad to hear it, too.

Thanks!

submitted by /u/dresdenologist
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