My wife had back surgery . It was mostly successful . Huge improvement in her situation . Months later we get a bill from the Hospital . Insurance denied , you owe us $60k . WTFO !
Insurance company says we don't cover that type of procedure . We were NOT told that prior to the surgery . Nobody seems to know why we were not informed prior . The surgeon scheduled it , we showed up , and away she went . We thought everything was good . Wrong !
Well , after two appeals denied my wife requested an independent third party review and they rather quickly ruled in her favor . The ruling is binding and the insurance company is going to have to pay . Most of it anyway . Being retired and on a fixed income this was weighing heavily on us . Thank God it worked out .
Moral of the story ? Assume nothing ! Don't trust the Doctors to verify coverage . When you sign that document that guarantees payment , you better KNOW you are covered and to what extent . We learned a valuable lesson . Won't happen again .

Glad to hear that it worked out. In the future, you might see if your insurance has a preapproval process. Mine does, and in fact requires it for non-emergency procedures.

Basically, you (or sometimes your doctor's office can handle it for you) contact the insurance company beforehand to notify them of the upcoming procedure and verify coverage.

Even if it's not strictly required, doing so could help you confirm that the upcoming procedure is covered, and change the treatment plan if needed before the procedure is performed.

A bit late piece of advice. I always call the insurance company prior to any “event” and verify it has been approved. They also send a letter stating as such. Ask them for one if they don’t offer it.

I just canceled a CT scan last week because it hadn’t been pre approved/authorized. Potential expensive mistake solved by one (actually more than one) phone call. Delayed it till this week, got the approved letter yesterday.

Insurance is a bitch. It’s a job all by itself.

I'm very happy that issue is resolved for you and your wife. I can imagine the stress you were under.

Some physician friends of mine have at least two people in the office full time that do preauthorizations for insurance concerns. It is just a gimmick on the part of insurance companies to avoid or delay payment.

Similar thing happened to me. I had podiatry surgery a few years back. This was in a hospital and in an OR that I work part time in by a podiatrist who I've known and worked with for years. His office told me that everything was good to go insurance wise. A month or two later, his office sends me a bill for his fees...not covered by my insurance. He, apparently, was not in my network and they neglected to tell me that.

Having been in the business for many years, I blame myself (mostly) for not having made sure prior, but I was lied to by his office staff who I trusted. Writing that check pissed me off and I lost a lot of respect for him and let him know that. It's been a tad uncomfortable working with him since.

Being assured of complete prior authorization ahead of time is the lesson.

To add, there is some truth to zsmichael's post. Insurance companies routinely deny a certain percentage of claims. Their hope is that people will not dispute that. Good on you for appealing it and having a favorable outcome.

My wife used to work in medical billing. She told me stories like this so when my operation was coming up, I called everyone involved and made sure all the referrals were called in properly and had the insurance company tell me everything that would be covered. Unfortunately, they really don’t know how much a procedure will cost, only if they will cover it or not. You can count on it costing your entire deductible.

quote:

Originally posted by RogueJSK:
Glad to hear that it worked out. In the future, you might see if your insurance has a preapproval process. Mine does, and in fact requires it for non-emergency procedures.

According to the Doctor's office , they DID call for pre approval and was told that no approval was needed . Well , you would think they might have asked WHY ? According to the insurance company , no approval needed because they are not going to cover it anyway . Crazy situation . A lot of people didn't ask enough questions and that includes us . We just ASSUMED that the Doctor's office handled everything . Most people do . Never again .

quote:

We just ASSUMED that the Doctor's office handled everything . Most people do . Never again .

Why does medicine get to operate like this? Very few (if any) other industries do.

Could you imagine taking your car in for a brake job, you go to pick it up and are presented with a bill, you pay it, and then leave with your car. Then over the next several weeks you receive bills in the mail from the mechanic, Snap On guy, and NAPA?

It is messed up. You don’t even get an estimated bill. A product of the end user not really paying the bill. (Unless you get screwed)

Yes, get it preapproved and in writing. Be sure all the doctors involved in the procedure (like anesthesiologist) are included too.

Glad you finally got things worked out. That’s one thing that Medicare seems to get right. They have an Advance Beneficiary Notice on non-coverage (ABN) that has to be signed by the patient before any non-covered procedures can be billed.

“The use of the ABN is required by Medicare to alert patients when a service will not be paid by Medicare and to allow the patient to choose to pay for the service or to refuse the service. If the practice does not have a signed ABN from the patient and Medicare denies the service, the charge must be written off and the patient cannot be billed for it.”

Basically the provider is the one responsible to get the patient’s consent to a possibly non-covered procedure beforehand and if they fail to do so, oh well, the provider eats the cost.

quote:

Originally posted by ZSMICHAEL:
Some physician friends of mine have at least two people in the office full time that do preauthorizations for insurance concerns. It is just a gimmick on the part of insurance companies to avoid or delay payment.

Unfortunately I have discovered a new twist in how insurance companies can screw you over. I checked and rechecked that everything was pre-authorized for my ACDF surgery last year. After the surgery, the insurance company said the hospital used the wrong surgery code when they filed, so they denied the claim because that code is for exploratory surgery which is not covered. They did pay some money to the hospital and last we spoke a couple of weeks ago they said everything was resolved last September when they made the final payment to the hospital. The insurance company now views this claim as closed. But the hospital is now telling me the insurance only paid some of what is owed and stopped responding to the Appeals Team request for resolution in September concurrent with the "final payment". All this is in spite of the correct billing code being refiled last June.

In the meantime, I'm discovering how long the insurance company can string you along being $2500 over the max out-of-pocket limit as per my policy. I have no idea if or when the insurance company will get around to reimbursing me for that.

Without revealing too many details, I too am in the middle of a little surgical drama.

Dr. office got 'pre approval' letter before the procedure late October. Completed before Nov.1.

Normal recovery & good results. Billing from clinic for $6k+ in Jan, stating procedure was denied as experimental, etc.

I was referred by my long time Internist, a preferred provider in their clinic. The specialist MD, a preferred provider in their clinic. Phone discussion with case manager mind Jan who says further review will be completed within 2 weeks. New billing early Feb for same amount.

I advised the case was under review. Got copy of authorization letter from the providing MD with date confirming pre authorization.

Never had such an issue with this carrier in several decades as customer.

Providers staff now active with carrier trying to collect charges on pre-authorizied procedure.