SIU procedures

[unsurepat]

Hello guys,

I had been outside the country (to my home country) and became sick during that time. I was admitted and charged a bill by the doctor. I did pay all the money and asked my insurance agency whether I could file a claim or not. They said I could definitely submit one. I went ahead and they mailed me the money which I had deposited. About a month or so later somebody from the SIU sent me a letter saying that they are reviiewing charges against me (because they feel that the charges are high - I have just sent whatever the doctor has billed me). They had asked for an explanation of benefits form which I filled out and sent to them. They came back to me asking for day-to-day reports and doctor details and I have diligently sent everything over. Still they wanted to investigate further and they have actually carried out investigations in my home country.

The investigation into the claim is still ongoing. Now my question is - I am not sure what the outcome of the investigation report will be. If they do determine that the charges are higher than what they are supposed to be (according to them) - how will the process go from there? I am very scared because I have never been involved in any kind of investigation before and I have nightmares about my insurance company deciding that this is some kind of a fraud (which this is not!!!) and just sending cops to my home.

[SpineAZ]

It is very hard for insurance companies to investigate and interpret services provided in other countries. This is a tough area for them - so make sure to work closely with them to provide them everything they need.

As with any insurance - they may determine what is "reasonable and customary" for the treatment received and may reimburse you that amount. Thus they may be requesting more information so they can see exactly what you had done.

In the US all bills for medical care use a universal billing code system. For example, the CPT code (universally used in the US) for a jaw x-ray is 70100. So if you lived in Oregon but got the x-ray in New York your insurance company could easily interpret what was done. If anything they'd need to see proof that you needed the x-ray.

However, someone who has a jaw x-ray in China (for example) wouldn't have the same "code". So some interpretation by the higher level claim folks (even SIU) is needed to flush out what really happened, etc. And, if your home country uses a different language than the country you live in - that requires even more work for the insurance company. It's hard to get medical information translated.

And, let's say your insurance company says $150 US dollars is the "usual and customary" fee for that service (again, only an example as I have no idea what the cost would be). And let's say the country you were in charges the equivalent of $350 US dollars for that service. The insurance company can say "we can only reimburse you $150.00".

It's not fraud until you accept funds you were not entitled to. So the worst that could happen is they deny all/some of the charges as they can not justify any/all of the charges.