Insurance crap....

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

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

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 said:

follow up

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!!

 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!!!!!

KTeacher said:

Notepad

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.

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

Crazymom said:

insurance

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

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 said:

I called the Onc's office...

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

 

Lets keep our fingers crossed that took cake of it.

debbiejeanne said:

its no wonder why its so hard

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

dj

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. :-(

phrannie51 said:

Whoop!!

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

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

Jamie