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Jun 06: dd is scheduled for surgery in Aug. I call Ins.Co. to verify that surgeon & children's hospital are in network. Answer: IN-network. (I'm not surprised, the surgeon's office is located on the grounds of the children's hopsital).

Nov 06: Surgeon is OUT of network. Charge for this portion of the hospitalization and surgery is $1500.

The fight begins, I involve my Human Resources department.. I am eventually reported to collections, and the debt appears on my credit rating.

Apr 07: Ins.Co. rep leaves voice mail message on Human Resource director's phone. "We made a mistake. Surgeon is IN network. We will reimburse the $1500 (I had paid the bill by this time) and write a letter to credit bureau explaining our mistake.) Check will be cut in two weeks.

May 07: Same Ins.Co rep leaves another voice mail message on same director's phone. "We made a mistake. Surgeon is OUT of network. We cannot reimburse.

Nov 07: At our annual "open enrollment" I spoke with the CEO of the Ins.Co. Nothing changed, nothing happened.

Nov 08: At our annual "open enrollment" I spoke with the CEO of the Ins.Co. They will issue me a check. Why? Well, who knows whether the surgeon is IN or OUT of network. BUT -- there is a clause in their policy that states that the surgeons/anesthesiologists/etc. who operate in an IN network hospital will also be considered IN network.

So I'm thrilled with my "found" money. But I'm also still livid that this entire episode transpired. What an stellar example of utter incompetence and what a total waste of time. Two and a half years to get this resolved...

Oddly enough, I had watched Michael Moore's Sicko for the first time this week!
 

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You know if the only 'reform' that we manage with healthcare comes in the form of more regulation on the darned ins. companies that alone would be a huge improvement.....:beat:

Glad you got it resolved......finally.
 

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Wow! Glad you stuck with it and were able to get it resolved even though it definitely sounds like the whole situation was a PITA.


Way to stand your ground!
 

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Glad you got it resolved. What a pain that it took so long!
 
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Oh wow, I'd have been livid! In the end, all that PITA correspondence and reversible credit damage could have been handled properly the first time. I'm glad you finally got things resolved though. :)
 
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WooHoo!
Glad your issue was resolved in your favor! One thing I always do is: read my Certificate of Coverage (COC). A COC lists your Policy's Benefits and Limitations, as well as your Rights as a Policyholder (it also contains complete information re: filing Appeals & Grievances). NOTE: your COC is, by Law, to be distributed by your Employer, as the Employer is the Group Administrator for your Plan (the Carrier will not be able to give you one; it must come from the Employer).

I also have the website/contact page for my State's Insurance Commisioner bookmarked in Favorites (as every State has a resource to assist Policyholders with issues just like yours).

Last, I was kinda puzzled that you did not mention that the Surgeon's billing office stepped up to help you...The claims issue directly affected his reimbursement (and you are probably not the only person to whom this happened). If it were one of the Docs for whom I was Practice Administrator, I would have addressed the issue for you - - as you (patient's Mommy) probably do not know the deep, dark secrets of insurance reimbursement. I would have also tag-teamed with the Hospital and asked that their Billing Director assist with the issue (I've worked for Docs who pulled out of Hospitals that they felt didn't 'protect' them/their reputation with insurance carriers).

Finally, I hate that you had to endure so many months of worry over what was probably a computer-programming error in the Surgeon's file with your Carrier (the cause of most payment issues)...And that you didn't have a COC that would have revealed to you that services rendered by a non-network Provider at a network Facility would be covered as if they were in-network (this is typically found under the "NON-Network services" portion of said COC).

Anna (who is proud of you that you persevered)
 

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I have only ONE thing to say: THIS is why we need universal single-payer medical care in the US.

Get the insurance companies out of the picture altogether. Retrain the claims people (whose only job is to find lame reasons to DENY coverage) to be truly productive, contributing members of society by working in ACTUAL MEDICINE, ie LPNs, RNs, OR techs, physicians, or whatever.

Our system is completely broken. I read that over 30% of "healthcare" dollars go to pay for the bloated insurance industry and not actual medical care. THIS MUST END.
 

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I'm glad you finally got it resolved.
 
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