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Old 06-04-2005, 08:29 AM   #1
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midlife05 HB User
Need some advice-This is long

Okay here is the long tale.

Went to my Urlogist he recommeded an implant procedure. They call my inssurance carrier. The dr office recieves a letter that approves the procedure on Feb 22, They catch the procedure code is not correct and get the right code verbal from the carrier(this is documented in the carriers system). March 16 the day surgery is done. Two months later all the bills from the various parties roll in and the Insuarance company isn't paying. I contact the carrier and my dr they have conference call how to clear the matter out, The dr files the appeal and it get rejected. Now this procedue was out patient and around 30k when you add it up. The hospital pre approved the procedure, They called me and setup the pre-op testing prior to surgery and told me my out of pocket. So the issue is I cannot order surgery and have no idea what the codes mean. I have escalated the issue. I,am trying to figure out the next step if they keep screwing me. Now this is no fly by night issurance carrier its one of the biggest.

 
Old 06-16-2005, 05:19 AM   #2
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dan_robinson HB User
Re: Need some advice-This is long

You're only 3 months into this. I suspect the doctor and the insurance will fight it out between them and eventually it will all get paid except for what you expected to pay out of pocket.
If you get an actual bill from the doctor demanding more, write a letter saying just what you said in this post and send it to the doctor. Ask them nicely to put your account on hold until the dispute with your insurance is worked out -- sometimes they send you a bill for the difference automatically without realizing (or caring) that they're also, concurrently, trying to get the same money from the insurer. Pointing this out will probably stop the bills until the insurance pays.

 
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Old 06-16-2005, 09:13 AM   #3
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froggy123 HB User
Re: Need some advice-This is long

My parents had a similiar issue with a recent knee surgery of mine. We were told that the insurance company would cover it, but we were getting bills that said our insurance company was not covering the bills.

All it took for us was a phone call to our insurance company - we told them that we were told this surgery would be covered, bla bla bla - and later find out that a person at the hospital didn't send in all of the paper work.

Something like this also happened with a knee brace, the brace was like $200 and we were again told the insurance company would pay for it, the company actually referred us to this company, then we get a bill that the brace was not covered. My mom called the insurance company, they looked up the code that was used, and that code was no longer active. So the insurance company called the brace company and gave them an active code to use, and then we got another statement saying that hte insurance company payed for it.


I would advise you to call your insurance company and talk to them. First and foremost though, make sure you get the full name of the person you are talking to. Tell them that your doctor got prior approval for this surgery, and you don't understand why you are receiving the bills - that you don't understand why the insurance company isn't covering the operation. Especially since there was prior approval.
If the person at your insurance company you talk to can't help you, ask to talk to a supervisor or someone who can help you. Be firm.
And definately mention that you had prior approval, and if possible, get a copy of the papers that stated this and have it in front of you, along with all of your bills when you are talking to the insurance company. It is always good to have documents that you can refer to.

Good luck and I hope I helped some!
I really hope you get everything resolved.
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Hi Everyone

 
Old 06-17-2005, 10:37 AM   #4
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Lenin HB UserLenin HB UserLenin HB UserLenin HB UserLenin HB UserLenin HB User
Re: Need some advice-This is long

midlife,

Are you talking about a penile implant? If so, I would think that's a dicey proposition insurancewise unless there was an accident to some kind.

What you need is WRITTEN PROOF that the insurance company OK'd the CORRECT code. Absent that, it's a he said-she said thing.

Can I assume the insurance company is saying they DID NOT pre-approve the procedure you got? If so then somebody is lying. Do you KNOW the doctor got the correct approval and the correct code or do you only have his say-so after the fact? In that case you have a defense against any claim he might bring against you for non-payment becaue HE screwed up the process.
If I had to GUESS, my guess is that the doctor never got the verbal approval and he's covering his tracks...but even if he did, a reasonable person would have asked for a confirmatory FAX to that effect.
I think ULTIMATELY your doctor and the hospital might be the ones stuck with this bill although you might wind up in a tedious court proceeding.

MORAL for the rest of us: Get everything approved in writing...then you know who's responsible for what, BEFORE the HIT SPITS the fan.

Last edited by Lenin; 06-17-2005 at 10:40 AM.

 
Old 06-19-2005, 11:49 PM   #5
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Kaylbe HB User
Re: Need some advice-This is long

You should check in your policy, but I've never seen one that doesn't include a statement of some type declaring that a pre-authorization is NOT a guarantee of payment. It boils down to the fact that we, as patients, are backed into a corner. We can't find out if a procedure is actually going to be covered until the bills and the specifics of your case are in the hands of your insurance carrier. Therefore you have to actually have the procedure done before knowing with certainty that it's going to be covered.

I have my doubts that the problem you are having now has to do with the procedure code being listed incorrectly on the pre-auth. I suspect that the procedure you had is either not covered at all under your policy or that your insurance is terming it as not medically necessary or experimental. As silly as it sounds it IS possible to be issued a pre-auth on a procedure that's not covered at all. Comparing procedures/codes with specific policy coverage is usually not part of the insurance pre-auth process. What might be deemed medically necessary for one person might not be so for another. That can only be determined after the procedure is completed and your pre-op history and diagnosis is considered together with the post-op diagnosis and findings.

The sad truth is that insurance companies are in business for one reason and one reason only: to make money. They do so by taking in more in premiums than they pay out in claims. Any glitch along the way can entice a company to deny a claim whether or not the denial is actually justified. They have learned that a certain portion of their customers will simply not question the denial and will pay the claim themselves.

Your first step needs to center around finding out the exact reason for this denial... It may already be listed somewhere on your EOB (Explanation of Benefits.) Next, I would contact the Department of Insurance within your state. You will have to submit a written inquiry outlining your situation and they will investigate the matter. If your insurance company's denial is indeed justified according to your policy, there isn't much that can be done. But if the denial was not just, the insurance will be forced to make good on the claim.

This is a lengthy process and since all medical expenses are ultimately the patient's responsibility regardless of insurance coverage, you will probably start receiving bills and possibly some nasty letters for payment from some of your medical providers. Make sure they are aware that you're working with the state insurance department but also start showing a good faith attempt on your part by sending in at least a token payment each month. This will help to protect your credit. It can take up to 90 days (if I remember correctly) for the insurance department to investigate your complaint and get back to you with their findings.

Best of luck and I hope this information was helpful.

--kaylbe

 
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