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Insurance crap....

phrannie51's picture
phrannie51
Posts: 3691
Joined: Mar 2012

It's beginning to look like I've been thrust into what may be common nowadays.  I had my scan in January under the new insurance....remember I had to cancel my appointment, and make a new one in a different town, because the local imaging center wasn't in my network....ok...did that.  Also it was pre-authorized by the Drs.' office, and I thought we were good to go.  This wasn't a PET, it was a CT with and without contrast.

I got my EOB yesterday from the new insurance company.....For the Scan they have it coded that "Charges denied.  Need documentation of medical necessity."

For the contrast they have "Charge not medically necessary".

I am SO upset!  Why would they authorize it, then deny it?  Is this the new way, maybe....that every time you do something they make you fight for it in hopes you'll go away and pay for it yourself?  I don't have any clue how to go about fighting this....do I go to the Oncologist's office and talk to them?  Do I just work with the insurance company?  So far with this new insurance every thing is coming out of my pocket.....the ENT isn't in the network (and he's the only one within 200 miles).....the imaging center isn't in the network, and neither is the butt Dr.  The insurance company doesn't have any problem, of course, taking $600 a month out of my pocket.

If anybody knows how to get this started, just the first footsteps, I'd be ever so grateful.

p

wolfen's picture
wolfen
Posts: 1194
Joined: Apr 2009

I hear your screams of frustration way down here in Arizona! I am in "insurance HE##" right along with you for different reasons.

I would start with the insurance company & see what documentation they need to show procedure "medically necessary". Would also check with billing person in doc's office to see if it was filed properly. Sometimes it a matter of coding. Sometimes it's a matter of stupidity on the insurance company's part.

Ron's teeth were pulled at the same time his port & I believe his feeding tube put in. The extractions were denied by Medicare as I guess they thought he just felt like having all his teeth pulled that day.  Finally got someone to understand, it was done in preparation for rads & it was paid.

I am still paying balances on hospital & one out of network infectious disease specialist. I fought UH on the disease specialist as he was the only one on staff at the hospital, but they wouldn't budge.

Good luck,

Wolfen

KTeacher
Posts: 928
Joined: Jan 2011

Get the notepad ready.  Keep dates, times and notes of conversations, even messages left.  I agree with Wolf--I had an appointment for a PET at Stanford.  I was told by caller that it was approved by insurance.  Sub plans, 2 1/2 hour drive, NO FOOD!  When I checked in I was asked how I was going to pay for this.  My sister nicely askes what it would cost, $12,000.  I started making calls.  Insurance company (BSBC) subs out medical tests to another company to approve, they do not talk to patient, will only talk to doctor and how did I get the number.  I was advised by Deb that we do have symptoms; aspirate food, think of some things that you live with that can be stated as symptoms.  Doctors will probably need to resubmit.  It is a pain and none of us need this frustration.  Do take notes, they will tape the conversations.

wmc's picture
wmc
Posts: 405
Joined: Jan 2014

Kinda funny they [Stanford] billed my insurance $12922.00 for the PET and everything and the insurance paid $5089.29 per agrement. I paid nothing then. But now it is a new year and my deductable is $3000 before they even start paying. The good news is I get to use their discounts.

I also have a dispute with a non-covered expence. They approved me having a TEP so I could return to work, and now they wont pay my SLP to check it. Then the next month they pay to have it changed, [replaced] becaus it was too long. Still have not paid the first one. It is a codding issue and will take some time to get it straight.

Looks as we all have or had this.

Best of luck playing there game.

Bill

Ladylacy
Posts: 476
Joined: Apr 2012

When my husband's insurance denied something, I checked to make sure that the doctor's office coded it properly because sometimes they didn't.  When you talk with the doctor's office get the name of the person who approved the test (they should have that written down).   Then I wrote a letter to the insurance company appealing the denial.  Put it in writing.  I also got to the point where when a PET/CT scan was needed, I called the insurance company to make sure approval was given.   Once I found out no one from the doctor's office had called to get approval.  Then I called the doctor's office and they gave me the name of the person who approved the test at the insurance company.  Then I called the insurance company back and gave them that information.  Also found out that many hospitals won't do the PET/CT/MRI without prior approval from the insurance company.

Whatever insurance companies, Medicare definitely included, can get out of they try.  Mainly because they don't expect many people to appeal and especially seniors.  I got good at filing appeals.  Always won and was always told due to error on clerk's part.  Yea right.

Sharon

debbiejeanne's picture
debbiejeanne
Posts: 2401
Joined: Jan 2010

P, its just a damn shame that we have to fight ins. companies as hard as we had to fight to beat cancer!!  they act like we ask for these tests because we think they're fun or something.  You're so right, they don't mind taking our premiums EVERY MONTH!!  fight them P, don't let them do this to you.  they are supposed to pay and i honestly believe they deny a lot of claims with the hope that we WILL say ok and pay the damn bill.  I'm sure you'll continue to get good advice here on where to start and what to do.  Don't give up on it, THEY OWE IT, NOT YOU!  I do agree with the others on codes, it only takes 1 wrong number for a claim to be denied.  call the office and ask about the code for sure.  good luck P, i'm sorry that you and others are having to fight this stupid fight.  let us know how it turns out, praying for the positive to be on YOUR side!!!

God bless you,

dj

PJ47's picture
PJ47
Posts: 332
Joined: Sep 2013

If your Md's office had it approved start there.  Ask the insurance person at the MD office who got the approval who they spoke to and the date and the authorization number (they keep notes).  THEN call your insurance co. to dispute the denial.  They cannot tell your MD office it is approved and then reverse the decision.  I am hopefull  the Imaging center made sure they had the approval number from your MD's office, they could be the weak link.  

It is remarkable that those trained to negotiate the health insurance maze are so incompetant that this kind of thing happens with great regularity.

I am still waiting for Vanderbilt hospital (since Nov) to figure out how to bill Medicare as secondary insurance.  This stuff should be a no brainer!  

So sorry you got caught up in the mess,

PJ

bjohn
Posts: 17
Joined: Oct 2011

This happens every other time to me at the same hospital for different tests. A lot of the time it has to do with how they sent in the information. Ask your insurance company who is responsible for getting approval. Mine says in fine print that I am not responsible if the provider does not get a test approved. They still try to send a bill but than drop it when I get the insdurance rep on the line. Good Luck. Very frustrating!!

ratface's picture
ratface
Posts: 1239
Joined: Aug 2009

 But they can be beaten as long as you play by the rules. Rule number one is, "it's business" so be business like. Every encounter is documented with date and contact person and what transpired during the conversation.

 

Rule number two: Find out what organization/authority they use as a follow-up standard. It's published in black and white. MY BCBS of IL. uses the National Cancer Guidelines. I've got a link somewhere.  You get a copy then go from there. If they require A,B,C then you make damn sure you fall within those parameters at some point during your argument.

 

Rule number three: Appeal and Appeal. Usually the first appeal is a seven day appeal for providing additional documentation.  They typically claim additional documentation is pending by your doctors office. They make one phone call to the general hospital phone and get the run around.  If the seven days pass without documentation, they win. There isn't a hospital in the world that can provide anything within seven days. This is where you provide the nurses direct phone number  and name that can provide doctors notes.  You send him/her an email that you are seeking help in upcoming scans. Fannie Mae is very useful here, Grease the wheels.  Don't be penny smart. I find that 50% of the time just asking for an appeal is enough early in post treatment. The more healthy you are the harder it gets.  The second appeal is troublesome for them because they have to submit all your documentation to an independent ENT to make a determination. This guy will go strictly by the standard of the authoritive body used by the insurance company.

There is a schematic flowchart that they follow, if patient has this then we do that. Here you get the doctor requesting the scan to directly call the reviewer. You will win another 50% of these.

 

Rule number four: You lose both appeals. Generally my condition worsens at this point and I develope a mysterious cough or begin aspirating food. This will be documentd as a new encounter with your ENT and You now start over with a new request. You generally win 100% of these.

It's not personal.  The moment you get angry they have the upper hand. It's a  game of cat and mouse. And you can be the CAT! Happy hunting!!!!!

 

phrannie51's picture
phrannie51
Posts: 3691
Joined: Mar 2012

I knew I'd find some experience here....just like I found it when I first got sick.  I am going to the Onc's office first with this, since they are the ones who set up the scan and got the authorization from the insurance company.....If it's "symptoms" they want, rads have left me with plenty of things that I can use. 

I don't get why they go ahead and give the authorization for something, then try to deny the claim after the fact....I've never been impressed with the logic of insurance companies, so I'm sure that would be asking too much.

p

Crazymom's picture
Crazymom
Posts: 295
Joined: Nov 2011

atta girl....keep fighting....i am very fortunate that my husband's company covers everything...I do not even get a bill...You are doing all the right things.  Contacting people who  know the laws and keep fighting...document everything......eventually you will succeed.....Ann

hwt's picture
hwt
Posts: 1907
Joined: Jun 2012

I've still got about $8000 for a PET pending more info. Atleast not denied yet but I maybe in for another fight. Still have a claim pending that Dept. of Labor has been trying to resolve for me. Apparently, my husband's former employer decided to take on insurance risks themselves and simply uses BCBS to do their billing. For that reason, they claim they aren't governed by the State Dept of Ins. but they do have to account to the Dept. of Labor. If we can fight the beast, we can fight the insurance company...however unfair that might be.

Good luck P 

phrannie51's picture
phrannie51
Posts: 3691
Joined: Mar 2012

and got the name of the person she talked to and the pre-authorization number....then she did some calling around, and found out that the new company has different Pre-auth numbers and got a new one that will date back to the day I had the scan (I got the name of that person and the new number too).  I don't know if this is all I need or not, since the insurance comp seemed to want "medical neccessity".  But it's a start.

There are SO many middle-men....the Onc sets it up with the hospital, the hospital submits the claim to another middle-man (CBA), they in turn subit it to the insurance company....hard to track where exactly the screw up took place.

I'm sure I'll be hearing from somebody if this didn't do the trick.

p

 

wmc's picture
wmc
Posts: 405
Joined: Jan 2014

Lets keep our fingers crossed that took cake of it.

debbiejeanne's picture
debbiejeanne
Posts: 2401
Joined: Jan 2010

its no wonder why its so hard to get a bill paid.....js

dj

donfoo's picture
donfoo
Posts: 1216
Joined: Dec 2012

Well, no wonder why health care costs SO much, way too much! There is no other product/service that is purchased where the buyer has no idea how much things cost. :-(

Duggie88's picture
Duggie88
Posts: 535
Joined: Feb 2010

Sounds like after a deep breath your making progress. If all else fails you can always make threats. (No Witnesses) All kidding aside, being a trustee on a large health and welfare fund I have seen many things that need changed but the system is set up in a way when someone forgot to dot an i it takes 3 people, two of which haven't a clue what is going on to correct it. If you just contact the same person everyday (one who is trying to dot the i) they will soon get it done jsut so the phone calls stop.

Idling doesn't move ya forward, put it in gear and lay some rubber, you will get results.

      Jeff

phrannie51's picture
phrannie51
Posts: 3691
Joined: Mar 2012

Got a letter from the Insurance middle-man that says my scan IS considered "medicaly necessary"....in small print it says that doesn't mean they'll pay it, but at least they're coming my way a bit.  There were cc:'s to both my Oncologist and to the Hospital....so I'm feeling light hearted at least temporarily.

p

PJ47's picture
PJ47
Posts: 332
Joined: Sep 2013

Positive!  I think if it is medically necessary than logically they should cover it!  Good news,

PJ

j4mie's picture
j4mie
Posts: 218
Joined: Sep 2013

That it looks like it should be covered! What a relief!

Jamie

Grandmax4's picture
Grandmax4
Posts: 585
Joined: Dec 2011

glad to know the insurance is coming around...I just got a bill, last week, from our local hospital dated December 1,2011...it's only for 14.97, why to keep up bcbs!

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