Ok, I had surgery back in January. I received a bill back in April that said my insurance company would pay 4565.00 out of a 5514.00 bill. That left me to pay 949.95. Fine and dandy, sounds good to me.
Today I get a call from the medical billing office telling me I owe 3278.50 out of 6867.00. She said she asked my insurance company, but they won’t pay.
I have absolutley no idea how to handle this. Should I get legal advice or am I just going to end up getting hosed no matter what?
You need to call your insurance company. Get the billing details. Go over your insurance policy with a fine tooth comb. Trust no one but your yourself.
Good luck!
Hey, Indygrrl.
Had the same problem once (insurance company said they wouldn’t pay for my breast reduction surgery, because they don’t pay to reduce three breasts at once. :eek: Turns out the folks at my surgeon’s office didn’t know how to code the form - a breast reduction is officially two surgeries, one on each breast- so they just marked everything that had anything to do with it! I’m now famous for being the three-breasted woman at Blue Cross/Blue Shield of South Dakota.)
But, never mind that. On to your problem.
First, check your policy and make sure that what you had done is not specifically excluded. Second, read what the appeals process is according to your policy. You will need to follow their procedure.
(In the meantime, definitely call your doctor’s office and let their billing department know you’re appealing the denial of coverage. Set up a payment plan - even if it’s $5 a month while your case in in appeal. That way, you keep in good stead with your doc, and when you win the appeal and the insurance company sends their payment, you’ll have a credit balance which the doc’s office will send back to you.)
This site has good tips on writing an appeal letter, should you need to. Yeah, yeah, I know it’s a site about a condition that causes excessive sweating… still, the steps it outlines are exactly the steps I took (more or less) to win my appeal.
Remember, insurance companies don’t care about doing what’s right or obvious a lot of the time. Sometimes, they will deny you hoping you will go away, or because there was an easily solvable error in the paperwork (see my three-boob problem above!!), but they don’t say that. They just deny you without an explanation. You need to follow their appeals process, and if you need to craft an appeals letter, you need to lay your case according to the terms of your policy (by specifically pointing out if your procedure is not explicitly excluded) and the medical necessity of what your docs office billed. You just can’t get emotional, because that won’t work. Make sure you cc: your HR benefits administrator, your doc, the highest level person at the insurance company that oversees appeals, and your state’s insurance commission.
Good luck. All is far from being lost!
Thanks guys, now the insurance co. is saying I owe $1164.05. Argh.
I’m going to wait until I get my Explanation of Benefits. Then I’m going to analyze it before I pay a dime.
At least the situation is improving 
It could also be some simple office red tape that will resolve itself (after you share your cheery voice with one of their representatives).
I received a “rejection” letter a week ago that momentarily raised my blood pressure until I realized that it was rejected because they never got that stupid signed letter from me saying that nobody else in my house had insurance coverage to share the burden.
I was still a bit pissed because that stupid coordination-of-benefits letter was in contact with the air inside my home for less than five mintues as I whisked it in from the mailbox, signed it, stamped it, and dropped it in the blue U.S. Mail box on the corner.
I called them up and the nice lady told me that everything would be taken care of and that the claim would be paid.
As far as hoops go, this one wasn’t too hard to jump through.
First get the insurance company to pay anything they’re willing to pay.
Then shake them hard, look for any clauses; do an official appeal with the insurance company. Give them a while to respond (but chances are good that they will drag their feet). Find out who the state organization is where you’re at that has authority to do an overview of whether nor not insurance companies are making good on their obligations, and file an appeal with them, too, noting that the insurance company has not responded to your request for an appeal, and then let the insurance company know that you did so. More often than not, people who put up a fight get a lot more of their costs covered. Insurance companies like to portray themselves as making decisions in a very mechanical, automatic rigid clause-driven way, but that’s not really the case. Things are a lot more in flux than they’d have you believe, and many insurance companies will almost automatically reject any expensive claim just because a decently high percentage of those rejections will go unchallenged by the insured party.
OK, by the time you get rulings and whatever coverage you’re going to get from them, the hospital will be practically hopping around like a little kid that needs to go to the bathroom. Give their billing department a call and do some negotiating:
“Hi, I see that my insurance company finally paid all but $1,395 on this bill. What will you accept as payment?”
“Umm, well, you need to pay us that $1,395…”
“Not gonna happen. I’ll give you $500 right now if you write off the rest. You’ll be getting considerably more than you’d be getting if I were a Medicare or Medicaid patient, and you would accept those payments readily enough. Your prices are artificially high in order to get as much as possible from insurance companies and we both know it. Take the $500 now or you can keep sending me dunning notices for the $1,395 from now until my great-grandkids are retiring. I’m contemplating bankrupty so I don’t care about my credit rating. You’re going to lose more than the difference between the 1300 and the 500 I’m offering you in interest and processing alone. I’ve got the checkbook in front of me, now are we doing business or what?”
(Get the biz department person’s name and title, btw).
I have worked for four insurance companies over the years, and in none of them was this even remotely true. (But I haven’t worked for all of them, and I know that there are some bad apples in the business.) I know that it feels good to say this stuff, but for those of us who really try to do right by our members, it gets pretty tiresome after a while.
And please everyone don’t drag me to the pit to rant about your insurance horror stories… I know they’re out there, and I’m not going to attempt to defend the behavoir of companies I don’t work for.
Having said that, AHunter3, I don’t in general disagree with your advice. I’d like to drill down further, though:
Indygrrl, is your policy an HMO, Point-of-Service, PPO, consumer-directed, or some other product? If it was anything other than HMO, did you utilize a non-network physician/hospital? Generally speaking, if you stayed within the insurance company’s network, the hospital has to hold the member harmless once the insuror has paid the bill (per their contracted discount). So, the hospital might charge $6000 “retail” for your service, but the insurance company may have negotiated a rate of $4000 for this service at that hospital. This means that, once you’ve satisfied any deductibles or copays, the insuror will pay the rest of the $4000 and the hospital writes off the $2000 difference. (That’s the “hold harmless” part - they can’t go after you for the difference.)
If you did NOT stay within the network, you would be typically be liable for your coinsurance plus everything up to the full $6000 billed amount.
Given that you apparently didn’t receive an EOB the first time, and that part of the claim amount was paid, there was no denial of service - the insuror thinks they’ve paid their portion of the bill. Typically you would only appeal a denial of service, as opposed to a payment for service at a lower amount than the hospital was expecting. I don’t know your situation in detail (although I’m happy to help offline if you want), but there’s a at least a moderate chance that it’s the hospital which is misbehaving here, not the insuror.
tpayne’s ideas are very sound ones and nicely written, may I say.
Indygrrl, please do keep at it and don’t give in to defeat. Many people out there wind up paying for things they shouldn’t because they assume that there is no way out or they don’t know what to do. Write letters, make calls, follow the advice given to you here, and see what happens. Good luck!
EEP. I am the entire billing department at my office, and while I am certainly willing to give discounts and set up payment plans whenever possible, if a patient spoke to me this way, they could forget about a discount and it would be off to a coellction agency. I don’t respond well to sassiness :wally
sorry wrong smiley. I don’t really think you are a :wally !
When you received the bill in April, was that from the insurance company or from the physician/medical entity who treated you?
If it’s the former, I would make a copy of the bill, plus a copy of any other correspondence you’ve gotten from them, and draft a letter explaining the situation, and ask why they decided to pay less than they originally said they would.
If it’s the latter, perhaps there’s a way you contact the doctor’s office and find out what they initially told the insurance company?
Question—there wasn’t anything unexpected about the medical treatment involved that elevated the projected cost, was there?
I agree with TPayne in many respects. I’ve been working as and IS person with an HMO for 2 years, and over 7 years as an insurance administrator for major Fortune 500.
Get the EOB from the insurance company, and a copy of the bill from the provider. Sometimes these two do not match, as we discovered on a $10K “misunderstanding” several weeks ago. Often just requesting these, and telling the billing dept that you are reviewing the bill may cause them to check it first.
And I also agree that it seems the hospital playing games, not the insurer. Everything depends on the coding from the hospital; fix that and most problems go away.
If you need additional help, gimme a shout.
I agree with booklover! It sounds like the only written bill you’ve received is the original for $5514 (total). The new amount is just something communicated over the phone. You should call your insurance company and ask what claims have been submitted by your medical provider. Did they file a claim for $5514 or for $6867? If they filed for $6867 then tell your insurance company that’s the wrong amount. Also find out what, if anything, your insurance provider has paid to your medical provider (the insurance company should have sent you documentation on that, unless it’s HMO or something I’m not familiar with). Then proceed as others have described above to ensure you get the insurance company to pay everything they’re obligated for.
Can’t believe I forgot this before: Ask the hospital to provide an itemized bill. I believe I read recently that they must provide this to you if you ask for it. There may be hidden charges or you’re getting charged for things you never actually received and it just all wound up in a lump sum.