Ever stare at an EOB and feel your stomach drop? Same. I’m Kayla, and I used a health insurance attorney after three denials in one year. It wasn’t cute. It was paperwork, phone trees, and a little crying in my car. But it worked. Mostly.
If you’re curious about every twist and receipt, I broke down the whole saga here.
Let me explain what I did, what it cost, and where it hurt a little. I’ll share the wins and the mess. Real numbers. Real forms. Real life.
Why I Didn’t Just “Wait It Out”
My insurer kept saying “not medically necessary.” I had a Blue Cross PPO. Good plan on paper. Not so sweet in practice. I kept a folder of EOBs, letters, and notes. I knew the dates. I knew the codes. But I still lost.
So I hired a health insurance attorney who handles plan appeals (ERISA stuff). We had a paid consult on Zoom. The fee was $250. She asked for my plan booklet (SPD), my EOBs, my denial letters (they call them “adverse benefit determinations”), and a HIPAA release so she could talk to the insurer.
I liked her because she spoke “insurance,” but she spoke human too.
Example 1: My Knee MRI Denied, Then Paid
- Issue: My MRI got denied for “no prior conservative care.” I had physical therapy and meds. They just didn’t read the notes.
- Plan: Blue Cross PPO, in-network imaging, CPT 73721 (yep, I learned codes).
- What she did: She wrote a tight appeal. She cited the plan’s own rules and my doctor’s notes. She asked for an “expedited appeal,” since I was in pain.
- Result: Paid in full. I had already paid $1,940 out of pocket. I got a refund check from the imaging center 6 weeks later.
- Cost to me: I paid the attorney $600 for the internal appeal letter. Flat fee. Worth it.
You know what? That refund felt like fresh air.
Example 2: Surprise Bill From an Anesthesiologist
- Issue: I picked an in-network hospital for a minor surgery. The anesthesiologist wasn’t in-network. I got a $3,100 bill.
- Law: This fell under the No Surprises Act. For a clear, plain-English rundown of your rights, see the official CMS fact sheet here.
- What she did: She sent a dispute letter to the provider and the insurer. She flagged the claim as a surprise bill. She used the UB-04 hospital bill and the EOB to show the mess.
- Result: The balance bill got wiped. I paid my normal copay and coinsurance. My total out-of-pocket was $200.
- Cost to me: $450 letter fee to the attorney. No percentage here. Quick win.
I could’ve tried on my own. But honestly, I was tired and a little scared I’d say the wrong thing.
Example 3: Teen Therapy Cut Off at Session 12
- Issue: My teen’s therapy stopped getting paid after 12 sessions. The insurer said “maintenance” not “treatment.” It was UnitedHealthcare. It felt wrong.
- Law words, simple: There’s a mental health parity law. It says mental health can’t be treated worse than medical care. If you don’t cap visits for asthma, you shouldn’t cap for anxiety.
- What she did: She filed an internal appeal, then an “external review” with an independent reviewer. She got a letter from the therapist with ICD-10 codes and a clear treatment plan.
- Result: Coverage restored and back-paid. We got $7,680 credited against our out-of-pocket.
- Cost to me: $2,000 flat for the full appeal and the external review. It took 9 weeks. A long 9 weeks.
I wish it moved faster. But it moved.
Example 4: Step Therapy for an Infusion Drug
- Issue: My plan wanted me to try a cheaper drug first. Step therapy. My rheumatologist said no. I’d failed it years ago.
- Plan type: Employer self-funded plan (ERISA). That matters because state laws don’t always apply. HR confirmed it was self-funded.
- What she did: She asked for a “step therapy exception.” She sent studies, my past records, and a doctor letter. We asked for “medical necessity” based on my history.
- Result: Partial win. I got a 3-month exception. Then they pushed the cheaper drug again. We appealed again and won a second exception. It was a grind.
- Cost to me: $300 consult, then hourly at $275 for this one. Total $1,375. Timeline: about 10 weeks from start to first yes.
Not perfect. But it kept me on the drug that worked. That’s a big deal.
What the Attorney Actually Did (Not Magic, But Close)
- Translated the plan terms for me. SPD, EOB, prior auth—she made it clear.
- Pulled deadlines. ERISA has very strict clocks.
- Wrote appeals that used the plan’s own rules against the denial.
- Got doctor letters with CPT and ICD-10 codes. Clean and specific.
- Used state rules when it helped, and federal rules when it didn’t.
- Filed external review when we needed a neutral referee.
I still had homework. I had to gather records, sign forms, and track calls. I kept a simple log: date, person, summary, next step. A cheap spiral notebook did the trick.
The Not-So-Great Stuff
- Time. Even a “rush” took weeks. Waiting is hard when you’re in pain.
- Cost. My total legal spend across all cases was about $4,725. That’s real money.
- Calls. Sometimes the paralegal called me back late. Not awful, just slow.
- Paperwork. I signed HIPAA forms, appeal forms, release forms. It felt endless.
Still, the money back and the care approved? Big wins.
What I Wish I Knew Before
- Ask HR if your plan is self-funded. If yes, it’s ERISA. That changes the rules.
- Always get your plan booklet (SPD). The answers live there.
- Keep every EOB. Even the ugly ones.
- Ask for the denial in writing. You need the reason and the codes.
- Get your doctor’s letter. Short, clear, and coded.
- Put deadlines on your calendar. 180 days for many appeals, but check your plan.
- If it’s a surprise bill, say so. Use those exact words. (The Kaiser Family Foundation has a concise overview of the 2022 consumer protections here.)
- If mental health is limited, ask about parity. Don’t be shy.
It’s weird—this sounds like a second job. It kind of is. But a little structure saves your sanity. If you want an extra set of free, plain-language guides on how to read those gnarly EOBs and SPDs, the consumer toolkit at ASQH is a solid place to start.
When You Might Not Need a Lawyer
- It’s a $60 copay mix-up. Call member services first.
- You went out-of-network by choice. Tough to fix.
- It’s under your deductible, and that’s clear in the plan.
- Your doctor didn’t send notes. Fix that first.
When You Probably Do
- A big surgery, infusion, NICU, or cancer care gets denied.
- Your appeal got denied and you need an external review.
- Your plan keeps saying “not medically necessary,” but your doc disagrees.
- You’re just plain burnt out. That counts too.
- You’re fresh off a divorce and the judge made health coverage part of the decree—here’s a first-person look at what court-ordered insurance really involves.
Costs and How I Paid
- Consults: $250 to $300
- Flat appeal letters: $450 to $2,000
- Hourly: $225 to $350 per hour where I live
- Total recovered or saved for me: About $12,000 across cases
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