Two Days From Surgery And Insurance Refuses

momall25ofu
momall25ofu CSN Member Posts: 81 Member
edited August 2018 in Head and Neck Cancer #1

Just found out insurance is refusing to approve his treatment again.  NEVER get an HMO.  They're saying they approved the doctor and the hospital, not robotic surgery.    We had a huge fight to get it to the teaching hospital.   They KNEW we were asking for robotic surgery.  It was the REASON we were able to get the referral .... my hospital has a medical deficiency -- no robotic surgery -- so they allowed us to go out of network.  Now they're saying NO to the robotic surgery two days before surgery.   I'm grateful my daughter is a lawyer.  We've already called and left a message for someone to call back.   I do believe in prayer and I've seen my Lord work miracles before.  I'm asking for one again.  

 

*** UPDATE *** They approved him for the surgery and for staying at hospital day of surgery only.  We're goingfight it and try to get them to extend it to the three days the surgeon asked for.  I'm grateful for the approval.  

 

Comments

  • wbcgaruss
    wbcgaruss CSN Member Posts: 2,577 Member
    #2
    Thankful for you

    that your approval went through after all and praying for you and that you get the hospital stay extended to 3 days. It might be a good idea for folks if it's possible to have any approvals sent to you in an email so you have a record of it and can also print it out.

  • ericyvonne
    ericyvonne CSN Member Posts: 7
    edited August 2018 #3
    My husband was in hospital

    My husband was in hospital for 3 days, very necessary!!!!  Best of luck!!

  • johnsonbl
    johnsonbl CSN Member Posts: 266 Member
    #4
    I spent only a single night...

    Very possible that he's able to go within 24 hrs.  Trust me, you don't want to be in the hospital.  Hospitals make people sick...  Get out of there as soon as possible.  He'll heal much better and faster at home.

    It's very similar to having your tonsils out...shouldn't be more than a day...  Everyone is different though.

    Good luck.

  • Mavish
    Mavish CSN Member Posts: 96 Member
    #5
    I will be praying for you and

    I will be praying for you and your husbund

  • momall25ofu
    momall25ofu CSN Member Posts: 81 Member
    #6
    Thank you friends.  He’s back

    Thank you friends.  He’s back in surgery. 

  • AnotherSurvivor
    AnotherSurvivor CSN Member Posts: 384 Member
    #7
    Which HMO are you using?  I'm

    Which HMO are you using?  I'm with Kaiser-Colorado and get excellent care.  They have decoupled the medical providers from the administrators.  If you have a lead medical provider I would work thru them and their team.  It's risky for an administrator to say No to a doctor.  I ask for nothing from the admin side of Kaiser, I just let my docs order stuff.  If a doc deems it within the Standard of Care and the admin side pushes back, the admin side assumes liability.

  • momall25ofu
    momall25ofu CSN Member Posts: 81 Member
    #8
    We're with Aetna HMO.  In our

    We're with Aetna HMO.  In our HMO, our provider couldn't get anywhere.   Its ok now ... He's in surgery and I'm glad theyre cutting the C out.  

  • tommyodavey
    tommyodavey CSN Member Posts: 729 Member
    #9
    TORS

    Did they approve the TORS?  

  • momall25ofu
    momall25ofu CSN Member Posts: 81 Member
    #10
    Yes, yes!!  I forgot to

    Yes, yes!!  I forgot to repost here.  He's post surgery now and doing pretty dang good!

  • hlrowe
    hlrowe CSN Member Posts: 80
    #11
    If the Carrier (Insurance)

    If the Carrier (Insurance) denied past the initial 24 hours as not medically necessary, the Hospital (Provider) can do a L1 appeal. If the carrier denies (upholds denial) the hospital can issue a L2 appeal, submission of medical records and itemized statement. Sometimes that involves a peer-to-peer physician meeting over the phone. Either way the patient is never on the hook for medical necessity denials. The hospital either gets the denial overturned or they write off the costs.  My company does denial management for several large teaching institutions.

     

    Mojo sent for a good recovery ----------------->

  • momall25ofu
    momall25ofu CSN Member Posts: 81 Member
    edited August 2018 #12
    hlrowe said:

    If the Carrier (Insurance)

    If the Carrier (Insurance) denied past the initial 24 hours as not medically necessary, the Hospital (Provider) can do a L1 appeal. If the carrier denies (upholds denial) the hospital can issue a L2 appeal, submission of medical records and itemized statement. Sometimes that involves a peer-to-peer physician meeting over the phone. Either way the patient is never on the hook for medical necessity denials. The hospital either gets the denial overturned or they write off the costs.  My company does denial management for several large teaching institutions.

     

    Mojo sent for a good recovery ----------------->

    Thank you for the info,

    Thank you for the info, HLrowe.  That will help me with anything down the road.  

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