Grrrrr....Insurance company rant.

**Kimberlina** · 01-07-2006, 10:48 AM

This will just be a brief rant.

We got prior approval for DDs surgery, and it was to be covered at the in-network rate, and when I clarified this with the insurance company, they said it would be covered 100% (which is correct, according to my benefits handbook and the in-network charges.) Today I got an invoice in the mail saying that I will need to pay at least $600 for her surgery, and possibly up to $1500 more because they denied EVERYTHING except 25% of the operating room charge.

I am SO angry. And of course they don't have any customer service on the weekends. Grrrrrrrr.

I have their letter saying it would be covered, but still, why don't they check this stuff first before billing people and causing all sorts of trouble? I paid $9000 for insurance for DD and I last year, and we only used about $300 or less worth of medical services all year prior to this. *%&#(!@ insurance companies!!!!!!!

**Pepper** · 01-07-2006, 10:54 AM

I hope you can get it straightened out

**Kimberlina** · 01-07-2006, 10:55 AM

I'm hoping the mix-up is just because the surgery got moved up two months. (And they should be glad it did, becuase the surgery would have taken even more time in the OR if it hadn't.)

**Darlene** · 01-07-2006, 10:59 AM

Glad you have it in writing that they approved. Sorry they are giving you the run around.

**AmyBoz** · 01-07-2006, 12:16 PM

Good thing it's in writing! Just have them resubmit and don't pay a thing.

**missmollymayhem** · 01-07-2006, 01:01 PM

Definately file a dispute!!! Insurance companies will wriggle out of anything they can, it seems.

**SHOPGIRL** · 01-07-2006, 01:13 PM

Check with the doctor's office to see if they entered the correct code. They might have just entered the wrong code. I'm sure it's a mistake.

**Mom23boys** · 01-07-2006, 01:21 PM

I am also glad you have the approval in writing. Hopefully it is all a big mistake.

**dwallyfam** · 01-07-2006, 02:33 PM

Kimberly

Like Shopgirl said make sure they used the same exact code. Also, they need to tell you exactly why they denied it. The codes at the bottom can be misleading. Also, see if they have a website. Some insurance companies are going to where you can check on claims and denials via the web.

Once you check those out you, if you want to, PM me and I will be glad to see what other things I can tell you to do to get it paid.

Kellie

**beandsemom** · 01-07-2006, 05:17 PM

Don't you hate the way they send out their bills so you get them on Saturday and have all weekend to stew about it?!?!

**Kimberlina** · 01-07-2006, 05:42 PM

That is exactly what I thought about the timing.

**dwallyfam** · 01-07-2006, 06:23 PM

Kimberly

I did think of one other thing. Is the Dr. still on the approved list? If he moved off, they will charge you more. You can check it by looking online at the insurance company website.

kellie

**my4littlebuffaloes** · 01-07-2006, 07:25 PM

This EXACT thing just happened to us. We had to go out of network for a necessary surgery for ds in October. In November the hospital billed us for $2000, claiming that our insurance only covers 60% out of network. We panicked of course. We called the insurance company and they said absolutely do not pay it. They had a rate with the hospital and they are not to charge more than that. But apparantly the hospital thought they would just bill us the difference and see if they could get any money. It actually made the insurance mad that they were trying to do this. LOL We are still fighting it, but our insurance is saying don't pay it. Hopefully you will get it straightened out!

Jennifer

**Kimberlina** · 01-07-2006, 07:26 PM

Yeah, he's approved. Actually, his charges aren't even on this statement.

There are two things that may be at work here:
1)I work at a hospital, and our plan only provides 100% coverage for surgeries done at our facilities. Since there is no eye-surgery set-up at my hospital, DDs surgeon and I both fought the health insurance to get it covered. At first they denied it, then they gave in and pre-approved it. I was told it would be covered at the in-network rate, and then I very specifically said, "so it will be covered 100%?" Christine, one of the appeals nurses, told me yes. If the surgery was in-network, it would be completely covered, so since they were treating it as in-network, it would be covered 100%. This is why I don't think it is an ICD-9 coding issue or anything like that. There are two different in-network possibilities- using my hospital is covered 100%, and then there is a thing that says something liek non-SPH (where I work) par facility, deductible plus 20% copay, but as far as I know, there ARE no participating facilities. Furthermore, that dumb nurse told me it would be covered 100%. I think she was probably wrong, and the letter I got was also wrong, as it said the surgery with the surgeon would be covered, which was never the issue. He is part of the network, so HE is covered. It was the specialized facility that was in question. So the letter and phone call may do me no good. I think the nurse was just flat-out wrong and it will be charged at the in-network, but non SPH rate.
2) The surgery was moved up two months, so maybe there is a problem with that, since the letter specified a certain date. I know that won't change the appeal decision, but perhaps it is just a computer error because of that.

**dwallyfam** · 01-07-2006, 07:46 PM

Kimberly

Usually dates don't change things a whole lot. It is the facility. The Drs. office probably forgot to include a copy of the approval notice with the billing saying that there was a override on the facility portion. When you call on Monday, ask to speak with Christine and let her know what is going on. She probably will be able to clear things up the fastest and may be able to get the payment issued ASAP. Make sure you note time and date of call.
Drs. billing staff often forgot sometimes to include any special details in with the billing and the claims people are under a lot of pressure to get so many claims processed an hour that they don't check special notes. FYI, be nice until you have to be a bitch and it should all work out.

Kellie