Before Luigi Mangioni, I was unaware of the reality that is the persistent denial of claims in what is American health insurance. Until I was sent such a denial notice on October 2, 2024 for my unanticipated Diverticulitis attack on July 4, 2024, that totaled $17,985.09 at that point. It has since reached $23,400.09 as more claims were submitted. Fidelis Care, under the NYS Essential Plan, denied the care provided on July 5-6, 2024. An appeal was filed by someone not me - I did not know about it - on September 12, 2024. By October 1, 2024, Fidelis sent a Final Adverse Determination Denial Notice to me confirming that they decided “we are not changing our decision to deny your inpatient emergency admission.”

From the time I received the letter, I had 4 months to appeal. The letter stated that if I didn’t agree with this decisions, I could “talk to a lawyer or someone else, like a family member [who can] ask the State for an External Appeal. This may be the best way to show how this service is medically necessary for you.”

This was stressful. I began dealing with this problem the week of Thanksgiving, when I had time to make phone calls. It was then I learned that on November 14, 2024, another claim was submitted for $21,934.12, which was paid. Reducing my amount owed to $100.

Thank goodness. But here’s what transpired for the denial process:

The Wording Of The Denial Letter

The Final Adverse Determination Denial Notice was worded in a scolding tone. It stated: “You asked for admission to the hospital because you had pain in your abdomen and a problem with your bowels.” The first part was true, but not the second. I had actually been bleeding vaginally for 2 months for unknown reasons, but resulted in my discovery of 2 small ovarian cysts. The letter continued: “You were not unstable. You went home the next day.”

A bullet list followed of reasons why I did not need the care I received. Some of that care included at least one line item of “Nuclear Medicine Inpatient” for $6,959, as well as room and board in the ER, lab work, CAT scan, ultrasound, more antibiotics to address the infection, etc.

The bullet list of denials stated: “These criteria are not met because the information provided did not show you had:

• Unstable vital signs that did not improve

• Severe abdominal findings on exam (indeed I was speechless with so much pain)

• Persistent significant bowel bleeding resulting in drop in blood counts

• Severe abnormality on imaging study such as bowl blockage or perforation

• Bacteria spread to the blood

  The letter continued: “The medical necessity for paying for your hospital stay at the ‘Inpatient’ level of care has not been established. Care can be provided at an ‘Observation’ level of care. These levels of care refer to how the facility is paid, not to care received. The request to approve your stay as an inpatient is denied on appeal.”

Symptoms And Reason For Hospitalization

The night of the attack, I felt sharp pain at 9pm. Having experienced a fully ruptured appendix 14 years ago, I recognized this pain as one that would not go away. But I went to bed hoping it would. At 3am, I woke up again, extremely nauseous. Having Vasovagal syncope as an adult, I now faint when I vomit. So I put pillows onto the bathroom floor to catch me, and lay down to wait it out.

The pain persisted and worsened. I woke up my daughter to have her wake up my neighbor to drive me to the hospital instead of calling the ambulance, just in case the added expense of an ambulance got messy. I rode in the back seat of her car lying down until we got to the ER at New York Presbyterian Hudson Valley Hospital in Peekskill (very much worth the drive, the hospital and staff are amazing).

I had no other symptoms of Diverticulitis. Based on my cycle bleeding, I suspected was experiencing a ruptured ovarian cyst. But no. The CAT scan revealed Diverticulitis. In the ER, two different doctors oversaw me, plus an OBGYN to address the mystery bleeding. One ER doctor insisted I stay overnight so that the four different antibiotics they were administering could control the infection. He was concerned the infection would worsen. As the antibiotics dripped via IV, my pain decreased slightly, but persisted. The doctor wanted me admitted overnight.

There were no available beds upstairs in the hospital, so they admitted me to my ER room as a hospital bed, and dinner was served on a tray. Later, I was transferred to a hospital room upstairs that was a conference room transformed into a room for two patients.

In the morning, I was anxious to walk around. Being a daily runner and skateboard pilates stretcher, my body is used to moving. During COVID, I walked off my infection then, so I got up to walk off this infection. Get the toxins moving. The nurses noticed me walking slowly in circles on the floor, balancing on my rolling IV drip, lapping the even slower patients who were doing PT for their legs. Sloths lapping sloths.

The nurses spoke to my new doctor, who when he came to see me, said that he heard I was trying to jail-break out. I would not have minded resting at the hospital, and the doctor encouraged me to stay, but the nurses nudged that if I was in this state, that I should leave the hospital to recover at home. We agreed, and I went “went home the next day,” as the denial letter described.

Receiving the Claim Denial Letter

Receiving the claim denial letter was frightening. The letter encouraged me to talk to my lawyer, but I don’t have a lawyer on retainer. I have my hair stylist twice a year, but that’s all I can barely afford.

I called the number provided in Fidelis letter, went through a bunch of extensions until I reached someone who was sympathetic. He told me to start with the Billing Department at the hospital, to log into the Fidelis portal to get more paperwork, and to call my attorney. Who was this mystery attorney?

Convinced that the doctors and nurses input the wrong codes, I called the ER directly to ask about the doctor mentioned in my denial letter. They told me to call Billing also, and to log into their portal to gain access to even more paperwork about my hospital stay.

Being a mother of 3 kids and a business owner, there is not much time in the day to chase these types of billing issues. If I worked as a medical professional or had more restrictive employment schedule, I’d have even fewer opportunities to fight this battle that had a 4 month deadline. I was one month in. The Tuesday before Thanksgiving, as I drove the kids to my parents during the work day, I had my 14 year old call the Billing Department on speaker while my other two listened.

The kids could not believe how much time this was taking. Digging into extensions, being put on hold, telling our story to whoever picked up. Finally, we reached Erwin in Billing at New York Presbyterian Hudson Valley Hospital. A Thanksgiving Miracle! Still incredulous, I asked Erwin to look a few more times to make sure. This seemed to good to be true.

A week later, I got a new Summary of Claims Activity report from Fidelis that stated that the Billed Amount had increased to $23,400.09, and that I owed $100. The insurance coverage seemed verified at this point.

I’m still holding my breath, waiting for more bills, but that’s the status as of now. Overall, Fidelis has been great insurance for no cost and low deductibles for those with low incomes who qualify.

As for the mystery bleeding, a midwife at the Women’s Center at Sun River Health in Beacon on Henry Street suggested that the infection was triggering my cycle every day. Once the infection cleared up, she predicted the bleeding would stop. She was right. I also saw Rebekah Azzarelli of Beacon Homeopathy to further discuss and manage the cycle. She mixed me a bottled remedy to be taken daily, and I’ve been quite pleased ever since.

I am grateful for the care, and believe everyone should be entitled to free health care regardless of income bracket, employment or marital status.