<p>Thanks, everyone, for your help. I was able to get to the root of the problem in 10 minutes with three calls. Now, I haven’t SOLVED it, but the issue is not the Dx code, but the procedure code the hospital filed, which does not match the one the doctor filed. If the hospital refiles with the correct code, all should be resolved. I HOPE!!!</p>
<p>Thanks, again.</p>
<p>Congrats --! I was going to also say that you need to look at the procedure codes – I had an experience last year where the insurance company insisted that the procedure code was not covered because it was for prescription meds – but I looked up online and could see that the procedure was for a surgical device, which clearly was covered. So basically the person at the insurance company was giving me either mistaken or deliberately misleading info about what code #XYZ stood for. (I still had problems and had to bring in some heavier guns to resolve them, but getting to the root of those codes was an important starting point. )</p>
<p>I think it should be required that they list an explanation of what each code stood for. I remember once calling a provider because I didn’t know what a particular code on my bill was. It turns out my insurance had been billed for a service which was not provided. </p>
<p>YDS, hope you’re able to solve it all quickly.</p>
<p>On a marginally related side note… we saved the delivery bills from when our kids were born because we thought they would enjoy seeing them as adults. Already those bills look cheap!</p>
<p>I’ve been an HR manager for 25 years. Insurance companies don’t go around denying for the sake of denying anymore very much. But they do have a bunch of very low level people denying claims and they don’t typically have any “outside of the box” permission to think. I’m dealing with a situation right now with one of my peeps Cobra claims. The insurance provider saw three checks, and they gave the guy credit for 3 months of coverage, even though he paid multiple months of premiums on a couple of the checks. It was easily straightened out. </p>
<p>I would start with the HR Manager at your husband’s company. I anticipate that he or she has a broker rep that they work with. My broker is awesome at helping me pinpoint the source of the problem. </p>
<p>Truthfully, it is really ultimately the doctor and the hospital left holding the bag if they did not obtain appropriate authorizations. That’s why they have taken over the preauthorization process from the patient. </p>
<p>Just work your way through. Start with HR.</p>
<p>Ooops…I see you are “resolved”. Nice work.</p>
<p>I had to leave so dh took over after my three phone calls. He called the hospital back, and the woman was less than helpful, but he finally got her to agree to call the doc’s office, find out what their procedure code was, get her mgr to look at it and then call me back in the morning.</p>
<p>Did I mention that the day of the procedure their computer was down and that they couldn’t even print my wristband? The anesthesiologist wouldn’t talk to me until he could get some kind of ID on me. The desk had misspelled my name, I corrected them and see on my bill that it’s still wrong. I don’t know why the hospital won’t just acknowledge quickly that they COULD be in error. ;)</p>
<p>
You must not be dealing with United Healthcare. They are the biggest slimeballs, who clearly are systematically, consciously denying reimbursement for covered services (which were verified in advance, and in some cases were also provided with “gap exception” coverage). No one, NO ONE can be that stupid as to make these “claims errors” over and over ,with new and different excuses, for over a year. My new word of the day for these claims reps (and their managers, and billing specialists, and everyone else talked to)- **Ignoranus (n): A person who’s both stupid and an a$$hole **</p>
<p>Jym, the problem I referenced in post #22 was United Healthcare. I agree with everything you say – I had a very similar experience. It was my daughter’s college policy, for a minor surgical procedure that was pre-authorized. (The clinic wouldn’t even work with her without the pre-auth.). I am pretty sure they were deliberately lying to me about procedure codes (as opposed to merely being stupid). Despite my legal background I was unable to resolve the situation on my own – but it was resolved once the insurance benefits coordinator for my d’s college got involved. (The college no longer uses the same company; they switched to Aetna the following year).</p>
<p>
</p>
<p>hahahahahahaha</p>
<p>[Lawsuit</a> Shows Insurer Targeted HIV Patients For ‘Rescission’ - Kaiser Health News](<a href=“http://www.kaiserhealthnews.org/Daily-Reports/2010/March/18/HIV-Rescission.aspx]Lawsuit”>Lawsuit Shows Insurer Targeted HIV Patients For 'Rescission' - KFF Health News)</p>
<p>And UHC has been sued in several states for the purposeful manipulation of the “reasonable and customary” fee calculation, that cost shifted higher copays for out-of-network docs to patients, by its wholly-owned subsidiary, Ingenix. It was clear fraud. [United</a> Health Care Out Network Fraud Lawyer Lawsuit United Health Group](<a href=“http://www.yourlawyer.com/topics/overview/UnitedHealth_Care_Reimbursement_Fraud]United”>http://www.yourlawyer.com/topics/overview/UnitedHealth_Care_Reimbursement_Fraud)</p>
<p>Each year different insurance companies rise to the top of my scumball list, and UHC has sat firmly in the position at the top of this list for a few years now. Benefits coordinators often are sold a line of BS and they and HR departments are clueless as to how their employees are getting royally screwed, unless the employee goes to HR and complains. PLEASE DO THIS. All too often the patient thinks the Dr/their billing office did something wrong (I believe that was initially true for the OP, who said elsewhere (and I am paraphrasing) that she thought the Dr sold her a line of bull). While sometimes the Drs office may make a billing error, all too often it is the insu co who does everything in their power to deny payment or stall payments. It is disgusting. Please don’t blame the Drs. They are doing their job taking care of patients. Posters here sound like they took an active role in the the correct processing of their claim. Thats how it gets resolved-- usually. But it takes time and the patience of a saint, and hours on the phone on hold, olny to be transferred or disconnected, not having calls returned, having claims denied over and over for legitimately and approriately covered benefits. HR needs to be aware of the poor way many insu cos are treating their employees. Living with this stuff day in and day out provides a better dose of reality. </p>
<p>There was a poster (can’t recall her name) who was the billing coordinator of a large medical practice who gave beautiful examples of the incredible BS she had to deal with on a daily basis. The isu cos love to let the patients think it is the Drs fault. We have had insu benefits depts tell us flat out that a benefit is not covered, but then tell the patient that it should be, and to go ahead and have the procedure and let the Dr bill it. They then flatly refused to have a 3 way telephone call when the inconsistencies in coverage were documented. They LIE to the patients. It is sad but true.</p>
<p>OK, rant over.</p>
<p>I think that they just figure that they can get away with it most of the time, so the numbers play out in their favor. Sure, some of the time people fight them and they end up paying out in the end, but even then there’s no penalty to them for late payment. It’s the patient who is getting all the collection calls and getting a ding on their credit, not the insurance company.</p>
<p>Actually, calmom, I’ve filed for all applicable penalties and interest on some of the claims. Got it on one so far. A whopping $42. It has taken me HOURS AND HOURS of calls and letters and trips to the PO to send certified mail (sometimes they don’t give anything but a PO box #, and we cant use fedex for a PO box so off we go to the PO, since we have to have proof they received the correspondence and the date it was delivered, as that is another of their BS tactics- claim they never received it). It is the principal of the thing. Really fries my cookies. </p>
<p>I will fight for my patients when the insu co is clearly jerking them around. But that said, the patient has to take ownership of their responsibility. All too often they figure they paid their copay and we must have done something wrong, so just ignore our calls or letters. That is not right. It is their insu co, not ours. The co will listen to them, the customer, not us, the cost center. We don’t want to have to send a patient to collections-- we want to help them get their claim paid. It is so frustrating.</p>
<p>Jym, ditto what you said, especially last paragraph.</p>
<p>HELP!</p>
<p>Woman at the hospital gave me a spiel about how she has professional coders blah blah blah and, basically, she does not want to change their code. I did get her to admit that they could be mistaken and that their office would call the doctor to try to get to the root of the discrepancy, but I can tell she really doesn’t want to work with me.</p>
<p>What can I say to her/do to try to get movement on this? I suppose I could just say “We can’t pay this.”</p>
<p>Stand firm. If they don’t change the code THEY WON"T GET PAID. Bottom line: you tell them that there is a discrepancy that means they will not be getting an insurance check. And the longer it takes to get this straightened out the longer it will be for them to get paid. Put some of this in writing. Ask to speak with a supervisor. Remind them that if you have to take legal action, all the while they will not be paid. You could always try for a conference call with the surgeon’s office insurance person/biller/coder, the insurance rep, you and the hospital. You could go to the hospital, meet with their coder and get the other two on the line via a conference call if no one backs down. </p>
<p>My guess is that once they realize the problem is resulting in their not being paid, something will change. Do not hesitate to call the hospital and ask to speak with a manager/head of the department in accounts payable and tell them there is a problem with a code. They are likely to call the coding office and try to rectify this so the hospital gets their check. They are actually the better person for the conference call anyway. The coder is the lowest person on the totem pole.</p>
<p>Ditto what sunnyflorida said. Go up the chain and talk to a supervisor.</p>
<p>And get a supervisor in Accounts Payable NOT in the coding dept. Coding is just coding and they think they have it right but they have no authority to change it. And they can be difficult to reason with. The more I think about this, the more you should speak with a supervisor or manager in the Accounts Payable or in the hospital BILLING (not coding) dept. (PS I am a physician and deal with hospital coders who think they have it right and are not going to budge, all the while the hospital is not getting paid.</p>
<p>And after you talk to the woman again, and to the supervisor and to everyone else, WRITE IT DOWN in a letter, explaining the doctor’s code, the hospital code, what it is and what it should be, etc. etc. Carbon copy EVERYONE, including your state’s insurance commissioner.</p>
<p>It’s amazing how quickly that cc line gets people’s attention!</p>
<p>Jym, when you talk about seeking penalties and interest, do you mean at the provider’s end when you are billing? Because I didn’t know there was anything I could do as a patient (or actually, the representative of one – I had to get my daughter to sign a waiver just so I could have the right to talk to the insurance co. about her claim) – and quite frankly, but the time it was resolved I was too exhausted to deal with them any further. My d. had been told that the insurance would cover 100%, but it turned out there was a 10% copay on the surgery — I read the policy and that part was accurate – so I really was glad to send off the copay to the clinic and be done with it. I made a point of regularly calling the lady in billing at the clinic – after 6 months of the runaround we were on a first name basis with each other – but I can see why patients would kind of give up on the process and want to leave it to the health care provider to deal directly with the insurance company. After all – the provider does know what all those codes mean – it can be baffling to the insured. I’m not sure that my d. could have handled it on her own, much less some patient who doesn’t have the education or legal background that our family does.</p>
<p>Yes, calmom,
I am asking UHC to pay all applicable fines and interest as they did not respond within the mandated time frame in processing some of the claims or appeals. If I could charge UHC for my time in dealing with their BS (and if they would pay it) I would be a rich woman.</p>
<p>And you sound like you took an active role in trying to get your daughters claims paid. We unfortunately have some patients, when their claims are not paid and when we need them to make a call to the insu co (sometimes the insu co will not talk to our billing dept about a specific issue, such as needing to provide some documentation of coverage or something) who dont respond to calls, bills or letters. They are typically here for an evaluation and then return to their referring doctor, so they are not patients we would see regularly in the office. It may take the patient calling their HR dept or the claims dept or to file a formal complaint, but they have to work with us. It is their bill, and their responsibility.</p>