<p>Insurance company says it won’t pay $8k bill for an outpatient surgery last month because they’ve deemed it “experimental.” However, they have paid the surgeon who did the “experimental” surgery. Anyone know what the discrepancy might be or have hints for how I should approach the insurance company?</p>
<p>TIA</p>
<p>Is the insurance through your work or your spouse’s work? Do you have a human resources person that you could contact? The HR person at our firm is great about knowing who to call in order to rattle cages and generally take care of business.</p>
<p>Good luck… these things are never much fun to sort through.</p>
<p>Dh’s insurance. I haven’t found them terribly helpful in the past, but it’s a thought. We’re hoping that because insurance didn’t have a problem paying the doc, that maybe the hospital billed the company incorrectly, using a wrong code or something.</p>
<p>Oh boy . . . you have my sympathy. I used to work for a company that dealt with several health insurance companies. One of our customers broke a finger and the insurance company refused to pay his claim because . . . a broken finger . . . is apparently a DISEASE. And, well, his policy didn’t cover diseases, only accidents, so they couldn’t POSSIBLY help!</p>
<p>I would call the doctor and get the dx code used by dr. Hospitals use a different type of procedure code, but the dx code should be the same. Call hospital billing to find out codes used. Try to figure out what went wrong. There is usually a pt. advocate that you can call at the hospital to help try to straighten out improper billing issues, but I have to say that when I had a problem I did not get much help from that area, but maybe yours will be different. </p>
<p>Remember to write an appeal letter within the time frame that your policy calls for and send by certified mail. For a bill of 8k I would consider taking an attorney if this is truly a routine matter and all else fails. ( I am a medical administrator so I am most familiar with things from the doctor’s office arena, but as to time for appeals it is critical not to delay.)</p>
<p>In Connecticut we have a state agency, [Office</a> of the Healthcare Advocate](<a href=“http://www.ct.gov/oha/site/default.asp]Office”>http://www.ct.gov/oha/site/default.asp), whose staff will assist with insurance issues like this…even making the phone calls on the patient’s behalf. Perhaps your state also has a similar resource?</p>
<p>Did you have the procedure prior authorized and after the fact they are trying not to pay? Did the physician’s office get a prior authorization? My office prior authorizes every single patient we take to the OR, even if it is just to get the name and number of a person who says no prior auth is needed. See if the office has a PA number or any notes when they called. Every surgeon has a staff who calls to see that the insurance is in effect, what the fee is the insurance will cover, if the surgeon’s fee is over the UCR (usual, customary, reasonable charge as determined by the ins company), what percentage is covered by the insurance and what is due from the patient. In the process, they determine ahead of time if there will be any problems. At least that is how we do it… Call and find out what info the surgeon’s office has from this process.</p>
<p>This is standard policy at most insurances. Most won’t cover experimental procedures, experimental drugs, and drugs not approved for specific indication. The latter is the hardest one to determine and most policies will only ask for a diagnosis for expensive drugs.</p>
<p>SunnyFlorida makes a good point about pre auth. The hospital or facility should have preauth also. I recall having a code for a perfectly routine surgery (dx and procedure) denied as experimental and when I called and complained (on behalf of insured) I got the old “oh, we don’t know how that happened” excuse. Did you by chance use a non participating facility? Use of a non par facility can cause a number of problems (not experimental rejection though). Hopefully your surgeon’s office can also provide a letter as to why the treatment was standard/routine/ etc.</p>
<p>I have started asking at Dr’s office if visits will be covered by insurance, even if I am pretty sure that they are. If there is a question, billing clerk can make a quick call to insurance before any charges occur. Of Course, this is not going to be applicable if I’m unconscious or have suffered some other type of emergency. But, I am asking more questions now, in advance!</p>
<p>I’ve occasionally had things denied. In almost all cases it was a mistake with the dx code, or miscommunication. Once it was denied because the provider wanted “more information” but they just denied it and when I called and found out they wanted more info, I just called the physician group and told them to contact the insurance company because they needed more info. Start dialing and hopefully you can get it resolved.</p>
<p>I had to appeal to my insurance co. after my d’s maxiofacial surgery was initally denied. I provided pictures, doctors, dentists and orthodontist’s letters to support the surgical need. It was a great day when I was reimbursed twenty thousand dollars of a thirty four thousand dollar surgery. I used an out of network doctor because of the extreme delicacy of the surgery. Had I not gone to the trouble of appealing, I would have recieved nothing. I have a secondary policy and I am still appealing with them although the maximum I can recieve from them is 3 thousand dollars.</p>
<p>As many have stated, it could be a clerical error…double check with all involved.<br>
I had a $5k claim denied due to “lack of coverage”. Turns out, my Dr’s office input my H’s employers name incorrectly. Somewhat amusing in that, employer is a 3 letter company that they misspelled (ACB instead of ABC)…
Be persistent…</p>
<p>One of my best friends in law school had worked for an insurance company. She said their orders were to deny, deny, deny (claims) and then to say, oops, must have been a mistake, when someone complained. They counted on people not to complain. Added LOTS to their bottom line.</p>
<p>Not surprisingly, she’s now a VERY successful plaintiff’s attorney.</p>
<p>Yep. The first inclination of the insurance company is to deny claims. Often, when you protest things, they’ll back off. I contacted my HR guy when I was hit with a bill for $500 for an echocardiogram that my doctor said was necessary. When I called the insurance company on it, they said, “Oh, right. Okay, you don’t owe anything, actually.” I was flabbergasted at how easily they conceded.</p>
<p>SOme ins doesn’t require pre authorization- however- what probably happened is that the code for the surgery triggered a reject from the computer, while the surgeons code did not- so the visit wasn’t looked at as a whole.</p>
<p>I had a recent test denied as " experimental" even though some insurance covers it, and another test that my insurance company does cover for the same information is much more expensive.</p>
<p>Sometimes it could be experimental for some things but not others- however it is just rejected out of hand, but then once the physician explains what it is for they say " oh… O.K.".</p>
<p>I also sympathize with Dr’s offices on keeping track of different ins coverage, but at the same time, I wish they could be more familiar with perhaps the largest companies like Blue Shield, because as a patient, I assume that the prescribed tests and procedures are covered, and that the physician will mention if one is " experimental", instead of just prescribing a whole bunch of things that may find repetitive information, that I may have to pay for out of pocket.</p>
<p>We particularly have trouble with mental health coverage. ( which I need for my medication- but D2’s Dr, doesn’t even * take* insurance)</p>
<p>Our Blue Shield policy subcontracts out the coverage to a company with very short list approved of approved providers ( Five in Seattle- three we have seen before & they are wack jobs- one doesn’t have openings and then the one I am seeing, who doesn’t see other family members). Only when the Dr. jumps through all the hoops of the subcontracting company, do they tell the main company it is OK to pay bill. Oftentimes there is mixups and it takes months to get it straightened out, in the meantime, the patient has to pay- but then it is the patient having to get it straightened out so they can be reimbursed.
Like I don’t have enough to do.
:rolleyes:</p>
<p>I’d try to appeal the decision by submitting a letter from the surgeon.</p>
<p>When my D was young, she was refused treatment for a surgery, that insurance deemed as cosmetic. I appealed, but it didn’t work. A few months later, I was watching the local news and another family was complaining about the problem of insurance not covering the same exact surgery. Long story, short…We banded together, along with some doctors, and testified before the Minnesota State Legislature and now everyone in Minnesota gets this surgery covered by their insurance company. The best feeling in the world was when I called my insurance company and said, “Not only are you going to be paying for my D’s surgery, but you are now going to pay for everyone else in this state.”</p>
<p>Toledo, that’s awesome!</p>
<p>toledo - way to go!</p>
<p>I’ve had quite a bit of experience being on the “not receiving” end of BCBS/Anthem largess. My advice: 1) don’t back down, 2) contact the appropriate “level”, e.g.–not the “no” clerks at the 800 phone number, go as high as you want (after a year of non-payment, a certified letter to the CEO got me a phone call within an hour after delivery) and 3) document, document, document.</p>
<p>Many of my issues have also involved coding, but that becomes a huge merry-go-round with the provider blaming the insurance and the insurance blaming the provider. Try to figure out what went wrong, and what is correct. Insurance is a nightmare!</p>