Warning - one method the insurance companies use to deny benefits - please read

[midlife_mo_Jo]

1) I had two biopsies and then a lumpectomy. Three different procedures on different days.

2)My insurance company pre-approved the surgery, the day-surgery hospital, the anesthesiologist, the surgeon. This is undisputed.

What is disputed is whether or not the the lab (pathologist) was pre-approved. The insurance company states that my surgeon did not "pre-approve the pathologist" so they are refusing to pay for those bills. Get this: the lab is on my list of providers, anyway, and my surgeon's staff assures me that they did notify the insurance company which lab was being used.

So, the staff at the doctor's office says they pre-approved, lab says they didn't have anything to do with it, and insurance company says lab wasn't pre-approved. Notice, nowhere in this saga did "I" do anything wrong.

WHAT IN THE HELL DID THE "INSURANCE COMPANY" THINK MY SURGEON WOULD DO WITH THE TISSUE THAT WAS REMOVED? THROW IT IN THE TRASH?

Anyway, I was treated for breast cancer last year. My prognosis is excellent - the very best. I'm done, I'm healed, I'm going on with my life. So please don't bother to make personal comments about my health. Truly, I'm fine. I just wanted to warn everyone of another possible scam by insurance companies.

You know, I'm not completely opposed to the concept of insurance companies. In the past, I've dealt with companies that paid all my bills, no questioned asked. I gave birth to a child with serious problems - total bill around $300,000, and we paid a $200. deductible with NO attempt to get one more dollar from us, but the unregulated state of things and the greed is totally destroying this industry.

Please recommend if you'd like others to read this. Thanks. (Is it ok to ask that?)

[LiberalHeart]

1. When my daughter had an approved surgery...

...her insurance company refused to pay the anesthesiologist's bill because he wasn't the one named on the request her doc put through in the paperwork. The one named wasn't working that day and this other guy, not in their plan, was on duty. I guess they should have just kept her awake during the cutting.

[Journeyman]

35. My 1 year old daughter had surgery for a congenital condition . . .

everything went according to plan and with the insurance company's approval, but when the bills were presented we were denied because it was "a pre-existing condition."

WTF?

Many messages, many snarky comments ("I was unaware we could only give birth to healthy children"), and months of persistent badgering, I finally got a lawyer to help me get what I thought we'd paid for all those many years.

That was over 20 years ago. And from what I read these days, it's worse now than it was then.

Single payer universal coverage. Womb to tomb. It's the only sensible approach.

[underpants]

2. Wow that is disgusting

What part of "insurance" don't the insurance companies get?

[rodeodance]

4. They only want to insure well people. simple as that.

[MorningGlow]

17. My brother was turned down for insurance coverage

He has IBS. They said it was too high risk, too life threatening. IBS??

[alfredo]

18. I'm uninsurable because I had a crohn's flare up in 1984. I had

to get a job at a place that had group insurance. That meant I had to take time away from my business to work at the post office so I could get insurance. Sucks.

[midnight]

3. Please forgive my response, but what candidate do you

think could clean up this industry?

[midlife_mo_Jo]

8. I've been pretty vocal that I'm for John Edwards.

He may have a small chance of winning, but I think there's still a chance.

I have other reasons for supporting him, but I won't clutter the thread by going off topic. I just wanted to warn people.

[dragonlady]

38. I agree. It will be a tough fight, and we need a fighter

John Edwards is the one who knows this and is "ready from day one" to do it.

Hi, Midnight! :hi:

[supernova]

5. I sympathize with your situation

Re: insurance companies.

Did you see Sicko? Insurance companies do hire people to comb through your bill looking for things to reject on the flimsiest of excuses.

[midlife_mo_Jo]

9. Oh, yes

[Emit]

6. I had a lab bill that I disputed for two years

(I won't go into the lengthy discussion, but basically, I went to the wrong lab because my doctor gave me the referral slip and the lab told me they were a provider when in fact they weren't)

I challenged it for two years, refusing to pay the lab and arguing with both the lab and the insurance.

I think they all just got sick of it. One day, almost exactly two years later, some big wig in billing at the lab just caved and said fine, we'll write it off.

It was the doctor and the lab's error, not mine.

[zorahopkins]

7. I'm So Glad You're Better. One Question, Though

I'm so glad you are better. As a cancer survivor myself, I know how terrible it can be.

I am wondering how much your insurance company is trying to stick you for.

Will you have to pay the lab bills?

[midlife_mo_Jo]

10. I have no intention of paying it, but my husband is worried

about collection agencies and credit reports.

At this point, I really don't give a damn. I just want to pay out my debts, and never borrow again, anyway!

[midlife_mo_Jo]

15. A few thousand.

That's three separate procedures where breast tissue was sent to the lab, as well as tissue from a sentinel node biopsy (negative).

[hobbit709]

11. My wife is having a goround with UHC right now.

The doctor put her on insulin for her diabetes. She needs to take a class on it. UHC says this is "major medical" and not diabetes maintenance. The difference is instead of a $30 copay they want her to shell out $450 we don't have. We're drafting a letter to the state insurance commission right now. A few years back when I was on NYlcare, I needed surgery and it was taking them forever to approve it. After 4 months of waiting I fired off a letter that included this

I AM IN CONSTANT PAIN, I AM UNABLE TO PERFORM SIMPLE BASIC TASKS. MY WIFE HAS TO BRUSH MY HAIR AND TIE IT BACK, PUT MY SOCKS ON FOR ME BUT I AM NOT GOING TO ASK HER TO WIPE MY REAR END FOR ME.
AS FAR AS I CAN TELL, THIS CONSTANT NEEDING A REFERRAL APPROVED EVERY TIME MY DOCTOR WANTS TO DO SOMETHING IS DESIGNED THROUGH DELIBERATE DELAY AND OBFUSCATION TO DISCOURAGE A PATIENT FROM GETTING MEDICAL TREATMENT. I AM STRESSED, ANGRY AND FRUSTRATED AND SERIOUSLY CONSIDERING CONSULTING MY ATTORNEY TO SEE IF THIS CAN SOMEHOW BE SPEEDED UP.

I sent this to them marked CC to the Texas State Insurance Commission and to my attorney.
Two days after I mailed this, my surgeon calls and asks "Are you ready for surgery on Thursday"
Amazing how fast it was suddenly done.

[KansDem]

12. I've noticed there's a piece of paper that makes *you* responsible for *everything*

I became an unwilling participant in corporate healthcare after a major health crisis during the summer of 2003. I noticed just about every time I signed a pile of papers, there was always one making me responsible for all payments, even those that I had no control over. And sure enough, many times I was told to check on something because the insurance company refused to pay. For example, I was taken by ambulance to the hospital. Cost: about $900. Well, the insurance company refused to pay because some minor detail was inaccurate. Meanwhile, the ambulance company was sending me letters wanting payment. This went back and forth for almost a year before it was resolved (I think someone at the insurance company finally called the ambulance company and worked it out).

The point is: the insurance company doesn't want to **** with the health-care provider and the health-care provider doesn't want to **** with the insurance company. So they make the patient the go-between to either cough-up the cash or resolve differences that will cough-up the cash.

[napi21]

13. Would you all be willing to name the ins. co's involved in these practices?

If you don't wish to, I understand. I really have no right to ask. So far, I haven't had any problems with ours not conforming to their promises. We have BCBS, and other than the annual $200 deductible and that damn 80/20 for all hospital coverage that has left us with bills of $2,500 for 2 years in a row (which we can't really afford), they have at least paid their portion per their commitment.

I'd like to see if there are certain ins. co's who are more prone to try to scam you.

[midlife_mo_Jo]

14. It's not one of the big names most people would recognize

And we do have insurance through my husband's employer, which is fully paid for by the company.

[fed-up]

16. I have to ship my neck/head traction unit back as "that model isn't covered" despite pre-approval

What is pre-approval good for if some lackey down the road can then reverse the decision? Why wasn't my physical therapist told only certain models were okay.

I have BCBS through medi-cal...

more like I have BS through medi-cal...

[midlife_mo_Jo]

23. That's totally insane.

Sorry about your problems.

[SoCalDem]

25. When my son's arm was paralyzed from a Brachial nerve injury

we paid out of pocket for a muscle stimulator thingie..cost $200 a month to rent the damned thing, but while the nerve regenerated, we could not risk having the muscles wither away..
The doctor wrote TWO letters and made a phone call, and they still reused to cover it.. It took 18 months, but he got back about 95% use of the arm..

if we had known how long it would take, we could have bought one..but who knows how long an injury will take to heal..

[philly_bob]

19. Outrage! My insurer didn't want to pay for anesthesia on colonoscopy! nt

[midlife_mo_Jo]

22. That sucks.

I've had one, and I had anesthesia.

[Ilsa]

37. Geez, you can have cardiac rhythm changes during a procedure

like that so you really need some anesthesia for that one reason alone.

Maybe we should ask the insurance committee if they want that big snakey scope stuck up their asses without anesthesia.

[Caria]

20. Keep resubmitting it

A friend who used to deny claims for a living told me that her employer had determined that most Americans will just go ahead and pay if the company denies a claim. Of those who fight it, almost all think in baseball "3 strikes you're out" terms. So her instructions were not to pay until a claim was submitted for the 4th time.

I had a lot of trouble with my HMO when I had BC too. Hang in there!

Caria

[midlife_mo_Jo]

21. Oh, I intend to.

[Caria]

24. And keep careful records

(you probably already are)

[Canuckistanian]

26. To me, this is bizarre to even have to think about this stuff

Are these the battles you have to go through to get a life or health-saving procedure when you HAVE insurance?

You really have to fight these leaches for every dollar?

That is so messed up.

For me, health care is simple. I'm sick. I go to the doctor or the hospital. I'm treated. I walk out.
My wallet never leaves my pocket, except to show my health card.

Why is this such a difficult concept for Americans?

[annabanana]

28. Oh we GET it!

In the NECK we get it!.. Everyone who has had any protracted procedure has run up against the insurance companies favorite dodges..

Thirty years of calling a National Health Plan "socialism" and "communism".. along with enforced ignorance imposed by complicit media coporations has paralyzed the populace.

The movie "SICKO" has punched a few holes in the box and let a little light in, and more people are furious than ever before.

I wish I knew how long it will take to get our "leaders" to bow to the inevitable.

[Canuckistanian]

30. I saw SICKO a few months ago

And even I was tempted to write a Congressman. And I don't even have one!

Your politicians must have hearts of stone to watch that movie and NOT be moved to change things. I suspect that many have studiously avoided watching it.

There's a lot of unrest out there. Whoever can tap into that could be the next president.

[Rosemary2205]

27. I am a Benefits Administrator.

Your first step is actually your husband's Benefits Administrator. They may have a contact within your insurer's office that handles these kinds of snaffus. If that company is too small to carry any weight with the carrier, or cannot help you then........

Sometimes the Billing office at the doctor's office can be of great help. Treat them as your ally rather than an enemy trying to pry money out of you and they are more likely to bend over backwards to help you resolve the issue. If that doesn't work either then.........


You MUST

1. Keep a record of every day, every time you call and exactly who you talked to for both the insurance and the billing office of the doctor and or lab and or hospital.

2. Put EVERYTHING in writing. Including keeping a written diary of every single thing you do regarding this situation.

3. Find out IMMEDIATELY what the appeal process is for your insurance carrier is. It's likely they will have a form for you to fill out but you may just need to write a letter to a specific person at a specific address. Do this RIGHT NOW. Detail everything. And I do mean DETAILS. You may need the help of the insurance coordinator at the doctor's office who got the pre-approval. You will need the date each procedure was pre-approved, any pre-approval code that was given, and both the ICD9 and CPT codes for the diagnosis and procedures the pre-approval concerned. Detail everything. -- SEND THE FORM OR YOUR LETTER CERTIFIED, RETURN RECEIPT. Delivery confirmation isn't good enough - you need a signature. Don't forget to keep a copy of every form, every letter you fill out or send.

4. Contact your State's insurance commissioner. Every state seems to put this office under something different so it may take a little homework - your state rep or senator (not your US congressman but your STATE rep) can possibly help you get in contact with the office that regulates health insurance in your State. -- Find out what the law is regarding filing an appeal with your insurance carrier. - Most states give the carrier 30-60 days to respond to an appeal but it's important for you to know exactly what the law is.

5. If your carrier denies the appeal, that office you contacted previously in your State government may be able to negotiate with your carrier to get the bills paid. Normally they do not get involved until after you have done what you can to resolve the issue through your carrier.

6. The last stop is a lawsuit. You are probably stuck with arbitration. Surprisingly, from what I've seen, when it's just a matter of paying the bill, the arbitrators tend to go against an insurance carrier if the request is in any way reasonable.

Good luck -- I do this everyday and it's no picnic for a sane healthy person. I did it with Prudential when I was quite ill and that was enough to make a sane person insane. I don't envy you at all.

[annabanana]

29. Thank you Rosemary

I'm about to embark on some supposedly covered elective surgery... I have copied your list and saved it.

[midlife_mo_Jo]

31. Thank you so much.

I hope you have this saved somewhere so you can help others with it. (Although I suspect you already have!)

Thanks, again!

My very best to you. :)

[Freddie Stubbs]

32. An authorization is generated whenever the insuranse company pre-approves something

Your surgeon either has a pre-auth number for the lab work or it doesn't. If he doesn't it is likely that someone in his office dropped the ball on this.

[Lydia Leftcoast]

33. I once read (in the New York Times, no less) an article in which

an insurance company CEO ADMITTED that his company routinely denies every insurance claim possible the first time, in the hope that the doctor/patient will give up and just eat the expense.

I wish I could remember when that article appeared.

[OzarkDem]

34. I'm a survivor, too

went through health insurance problems also, as my husband had changed jobs (and insurance companies) just prior to when I found a lump.

The new insurer tried to jerk us around, saying it was a pre-existing condition, but my health care provider ignored them, got me into treatment and dealt with them later. They eventually paid. Not all health care providers do that today.

A problem many uninsured women have today is, if they pay out of pocket for a mammogram and have a suspicious result, hospitals will refuse to let them make an appointment for diagnostic screening or a biopsy. They get bounced around until they find someone who will do the diagnostic work for a large cash down payment. The problem - if a hospital diagnoses you, they are obligated to treat you, ergo they will refuse to diagnose you.

My solution is something akin to a health care provider firing squad, but hopefully cooler heads will prevail.

[Ms. Toad]

36. Appeal it.

I am a veteran of fights with insurance companies, and I've won every one except the couple that I didn't follow through on because I was too busy handling other complicating events in my life at the time.

Make the point that you have no knowledge of who the hospital/physician chose (would choose) to use for the lab and there was nothing under your control as to which tests were done or where they were sent for verification. At best, the insurance company will eat the fees. At worst, the surgeon didn't comply with his contract and he will feel the financial hit.

That has worked for me when the hospital used anesthesiologist for emergency surgery and no anesthesiologist groups within 50 miles were on their approved list (insurance company paid it), as well as when the approved radiological technician sent the films to a non-provider radiologist for reading (doctor paid it, per his contract with the insurance company).

If anything is under your control, it is harder to fight - like if you went to a specialist and did not personally call to the insurance company to check and make sure the approval was processed before the visit. When something like what happened to you occurs, and you have no control over it, its a much easier battle.

The funniest one was when I had a biopsy to take a snip out of a mole that fell within the A-B-C guidelines for cancerous changes. Only a snip of the mole was removed, for the express purpose of biopsying the tissue to make sure it wasn't cancerous. They paid for the tissue analysis, but refused to pay for the "surgery" to remove it since it was "cosmetic." Pointing out that the mole was not visible to any but my intimates, that only part of the mole was removed, and that if I were going to remove a mole for cosmetic purposes it would have been the one in the middle of my face didn't sway them. What finally did was my question as to whether they would refuse to pay for a lumpectomy to remove a suspicious lump because it was cosmetic breast reduction surgery.