Insured plans ARE regulated, by individual states. Self-insured plans have to follow ERISA.
That shoudl have been a violation and if caught upon Audit…
When I was in MegaCorp Benefits, our Execs had an insured plan for that very reason. (The masses were covered under a self-insured plan.). Teh Exec plan paid 100% of nearly everything, unless ti was quackery. That said, even tho the Exec plan was insured, if an Exec pushed back against the Claim office, the’d call for advice, on whether to approve. If we said, yes, then they’d add it as an exception to the plan for all of the insured Execs and build it into next year’s rate increase. One of the last things I accomplished before I left was eliminating teh Exec plan – and they were not happy campers.
I hate seeing doctors because I really hate all the claims business. I have been lucky so far that I haven’t had to have a lot of doctor’s visits.
Here is my vent:
I had a regular physical early January with a very large medical practice. I had EKG and blood tests done. All of that should have been covered 100%.
I looked at my insurance claims and found out I owed $500+ to my doctor. When I asked Aetna they said the claim had a code for a regular medical visit, not an annual checkup. Aetna said it was up to me to contact my doctor to have them resubmit the claim with right code.
I also saw a claim from an urgent care I went to about my leg pain. They didn’t even have the right blood pressure equipment to take a reading and there was no medical procedure they performed on me. They submitted $285 for the visit.
There was a claim from CVS for a drug that I didn’t pick up and no longer in use.
All of these things are causing me time and effort to straighten it out.
Thanks for bumping this thread as I had quite the issue last week.
I take a specialty drug. Everytime I order it, dh and I are on speakerphone so he can take notes to state our case when they invariably screw it up. Last week I was on the phone for 1 hour and 42 minutes (one call dropped after an hour). The specialty pharmacy, Accredo, admitted that they screwed up in July, which affected October, and is why I was refusing to order again in January until it was fixed. But they said that I had to make all the calls to fix the $3k+ charge in July and the $6k+ charge in October. But here’s the deal – when we log in to Accredo, it showed a zero balance. How was I supposed to know that there was an issue?
I also encountered a new one this past week. A dear friend of mine was diagnosed with ovarian cancer. It is clearly quite advanced - the oncologist believes either stage 3c or 4. But the doctor can not say for sure because her insurance keeps denying her a pet scan.
8 years ago I went to a dermatologist for a skin check and to have a precancerous spot removed. It was paid by insurance as preventative. I just went to the same doctor for the exact same thing. No longer paid as preventative, so cost is on me.
They often pull a similar thing with colonoscopies. They are considered preventative so are covered, but if they happen to find a polyp during the procedure, then they become treatment even if you went into not expecting anything to be found. This happens while you’re asleep, so you have to sign a form ahead of time stating that you understand that the procedure MIGHT be preventative and fully covered or it MIGHT be treatment and subject to your deductible/co-pay. May the odds be ever in your favor…
I’ve been taking a pricey biologic Rx. It has to be pre-authorized. I’m supposed to take it every 2 weeks. I need to get my next 2 shots. I got notified that my pre-auth was rejected because the MD hadn’t sent his clinic notes. I called the md & insurer and they said they’d fix it. Supposedly it’s ok again and I’m supposed to be notified when it’s ready for pick up. I only want it if it’s pre-authorized because I’m not paying $36,000/yr to take this. With pre-auth, no copay.
The doctor’s office says they sent the lab order with a prenatal diagnosis, the lab says they filed the claim with a prenatal diagnosis. The insurance company says they won’t pay because there’s no prenatal diagnosis. I know the next step is for the lab to refile but damn, this feels intentional by the insurance company. Pretend it’s not right so you can deny and maybe it won’t get refiled and you will never have to pay. The whole system is so broken and the number of human hours that go to dealing with this kind of crap must be insane.
My sister was getting some specific depression treatments by a psychiatrist who specializes in that kind of stuff. They were covered by her Medicare plan so all went well. Then he proposed a more expensive, sort of edgy treatment. She wasn’t sure, but he urged it. The office said the plan was covering it as in-network. She tried the treatment three times, found it unsettling, and stopped it. Now the doc is billing her for thousands because even though they said that insurance said it was covered, it turned out it was out of network. Sis is very low income and can not possibly afford this. and as far as we’re concerned, the doc and insurance company need to work it out between them. But meanwhile, she’s getting friendly/threatening letters. It makes me so angry!
My gastro (who just left the practice) may not have been the world’s most talented physician, but he was a GENIUS when it came to coding!!! Now I’m going to have to see one of his colleagues, who is reputed to be an excellent doctor but hardly an insurance savant…
I don’t blame him- he allegedly keeps meticulous records, and their billing team just codes accordingly. But the previous guy had the magic touch and knew which nomenclature raised eyebrows and which procedures got paid with no question!
I just got a call from the medical center billing that I’m RIGHT! That must have killed them to admit. I called a number for an endodontist to do a root canal and I was looking for someone in network. The doc was listed at an office near me but when I called it was to the appt center at the medical center (where I went to lots of docs). I was very specific with what I wanted. Oh yes, no problem. Went down, checked in, told the receptionist that my insurance was the same for both dental and medical (same group number). She said you have a $50 copay, I said I did not. Oh, 10 minutes later they said ‘oh, we can’t do THAT root canal’ (even though I told them exactly what I needed). I called to complain. Never heard anything.
Get call from billing that I owe $107 for the non-visit. I said you need to bill it to insurance as a preferred provider. No, she says, you don’t have dental insurance. I DO. Well it is not on the card. Try turning the card over. First thing is dental claims.
Call today is that I was RIGHT, that they failed to bill insurance for the dentist. They also stopped sending me itemized bills sometime in July so I said I’m not paying anything until you itemize as this is the third mistake since July I’ve found (two co-pays miscoded, plus the one for a mammogram that they tried to make me pay $10 for - I have NO copays that are $10).
Oldfort, get Aetna to do a 3 way call with your provider/biller. That’s the only way I get things fixed (and why I left Aetna). Often the other two on the line are not fluent in English so it makes it extra difficult.
My son is dealing with a delayed development 19 month old. Nine months of various specialists…no answer. Finally gets to geneticist. Now they want a parental test.
Child specialist hospital asks them to cash pay and says then results would be within 3 weeks. Really shouldn’t file insurance because “they will deny, time with appeal, blah blah”. I’ve gone down this road before. It’ll be covered and it will take time on the part of the doctor/hospital. THEY don’t want to file and they want the patient to cash pay. Pressures them hospital will bill more if it’s billed through insurance.
It’s an in-network dr. and hospital. Who cares if they bill more? It’ll be written down to contracted price. I’m so mad they pressure young parents in this manner!!
I called my insurance company yesterday. Preventative skin checks are now only covered if they are at your regular doctor. If they occur at a dermatologist they are no longer preventative and my deductible applies.
So far, my colonoscopies have all been paid 100% even though they have found polyps every time. I expect that policy to change at some point though.
“…this feels intentional by the insurance company”
It absolutely is intentional. Part of their evil business model is that they delay/deny and then over time, some people will die; some will get new insurance; some will give up and pay on their own; some will give up and go into debt. And even if they eventually pay, the insurance company kept the “float” on that money. Times thousands and thousands of patients, sometimes millions of patients, that’s a whole lot of yachts for the plutocrats.
Opposite problem. On traditional Medicare. I was billed for a PA appointment over a year after the visit (no invoice / no EOB/MSN so assumed it was ‘covered’). MD billing office tried every way to pin it on me, requiring full payment (over the Medicare approved amount), saying I never gave them my Medicare information (although they submitted it to Medicare somehow), that payment was overdue (although I never received a bill until a year after the visit), etc. Full story is more complicated, but I was quite pleased with assistance from Medicare and state SHIP office.
No longer with that MD, which is unfortunate. MD and PA were fine. I realize the insurance mess it is difficult for billing offices as well, but in this case, trying to deal with the errors made by the billing office was a nightmare.