Author Topic: Insurance denying to cover surgery: What to do?  (Read 9156 times)

Rimu05

  • Stubble
  • **
  • Posts: 227
Insurance denying to cover surgery: What to do?
« on: January 04, 2017, 09:20:54 AM »
Hi all,

I recently had an appendectomy after getting a CT scan and I was expecting medical debt probably in the 3 grand range because of the ambulance ride (I had to be transferred to a different branch by ambulance), CT scan, etc.

Long story short, checked my insurance (Actually not mine, I am covered under my mom's plan until I'm 26) and they denied the whopping $43,000 surgical bill. Funny thing is, they accepted a good majority of the other bills except the surgery...

To say, I can't pay this is an understatement. This debt even exceeds my student debt by about 13 grand and I struggle to pay my student debt.

I'm 24, have good credit, but have student loans and a car loan (Yes, I know).

I'm going to call the insurance and see why in heaven's name they aren't covering this but I am a pessimist at heart and need to know what I can do here. Cause right now I feel like rolling over, throwing FI thoughts out the window and letting this go to collections forever.

Insurance company is BlueCross BlueShield: Never had any problems with coverage until now.

SimpleCycle

  • Pencil Stache
  • ****
  • Posts: 910
  • Location: Chicago
Re: Insurance denying to cover surgery: What to do?
« Reply #1 on: January 04, 2017, 09:27:12 AM »
You need to call them and find out why they denied it.  Chances are it was denied on a technicality of some sort that you can get worked out.  I recently had a $3k claim denied because they needed documentation of medical necessity, and as soon as my doctor's office sent that they paid everything except $120.

We can't really give you your options until you know why it was denied.  If you are in fact responsible for the bill, your options change, but you still have options.

I'm a red panda

  • Walrus Stache
  • *******
  • Posts: 8011
  • Location: United States
Re: Insurance denying to cover surgery: What to do?
« Reply #2 on: January 04, 2017, 09:28:11 AM »
Before you freak out: Talk with the hospital billing department- did they use the right codes? Do they have any insight on how it was submitted to the insurance that may have caused it to be denied? Can the doctor recode and resubmit?

Talk to your insurance. It may have been a mistake. Ask them why it was denied.  Can that reason be corrected? File an appeal if necessary.

Kapiira

  • Stubble
  • **
  • Posts: 152
  • Location: Albuquerque, NM
Re: Insurance denying to cover surgery: What to do?
« Reply #3 on: January 04, 2017, 09:46:09 AM »
If you don't get a satisfactory answer from insurance and/or the hospital, try calling back again.  Some associates are far more knowledgeable and helpful than others. 

Is the insurance through your mother's employer?  If so, her HR department can be a huge help in getting the bill sorted out.

Kapiira

  • Stubble
  • **
  • Posts: 152
  • Location: Albuquerque, NM
Re: Insurance denying to cover surgery: What to do?
« Reply #4 on: January 04, 2017, 09:52:20 AM »
Also, you should know that having insurance deny a claim like this is totally par for the course.  It's not unusual at all, and in all likelihood you will get it sorted out after numerous frustrating phone calls. 

mm1970

  • Walrus Stache
  • *******
  • Posts: 6863
Re: Insurance denying to cover surgery: What to do?
« Reply #5 on: January 04, 2017, 09:52:44 AM »
What they both said.

It's pretty much standard, in my experience, for insurance to deny surgery. I wonder how many people just pay the bill?

Childbirth for kid #1:  Got a bill for $3000 out of a total $8400.  But wait, my insurance?  Got my EOB from insurance.  Got a bill from hospital.  None of the numbers add up.
Call hospital.  Ask them about it.  They say "let us look into it".  They resubmit (I assume with the correct billing codes): magically, bill is $700 (deductible x2).

Surgery for kid #2: medically necessary when he was 9 months old.  Requirement: 1. go to pediatrician, get referral to specialist.  2. go to specialist, get referral to UCLA because specialist no longer performs surgery on children (wasn't doing enough to stay current) 3.  Get the pre-approval code. 4.  go to UCLA for surgery.

Surgery is $20,000.  First letter from Blue Cross HMO is "we are denying payment as this was not emergency surgery".  No shit.  That's why we went through the pre-approval process.  Per my insurance coverage, cost should be $125 for outpatient surgery.

It took 18 months to work it all out, so be strong!  In the end, the requirement was that UCLA needed to send the info to our home clinic.  We are required, in the HMO, to have a home doctor's group/ clinic.  The home doctor/ clinic is the one to submit the claims to the insurance.

You will have to call everyone and their mother to work this all out.

The Happy Philosopher

  • Bristles
  • ***
  • Posts: 343
    • thehappyphilosopher
Re: Insurance denying to cover surgery: What to do?
« Reply #6 on: January 04, 2017, 10:06:50 AM »
There is no possible way BCBS won't cover an appendectomy. Most likely is had been coded incorrectly or some other administrative mistake. First call the insurance company, if that doesn't clear things up call the hospital. Keep making phone calls until someone fixes this. I would estimate 20% of my medical bills require a call to someone to clear things up. I am almost beginning to believe it is intentional, that they are just hoping I'm lazy and will pay up, although I think using Occam's razor it is most likely incompetence. If I ever get really sick I hope I'm not working because dealing with medical billing can be a part-time job! Good luck :)

katscratch

  • Handlebar Stache
  • *****
  • Posts: 1326
  • Location: Minnesota
Re: Insurance denying to cover surgery: What to do?
« Reply #7 on: January 04, 2017, 10:30:59 AM »
My son's surgery last year was originally denied because he didn't have his insurance info at the time and it was submitted under self-pay instead of under my insurance.  That first bill was a big surprise, well over $43k ;) 

He called the hospital, made sure they had his correct information, and the bills were resubmitted - within the month we had the new bill that was correct. 

honeybbq

  • Handlebar Stache
  • *****
  • Posts: 1218
  • Location: Seattle
Re: Insurance denying to cover surgery: What to do?
« Reply #8 on: January 04, 2017, 10:51:02 AM »
Yep, call.

All I can think of is that you were transferred via ambulance from an in-network hospital to an out of network one and that has confounded everyone.

Keep calling and asking the relevant questions.

Bicycle_B

  • Handlebar Stache
  • *****
  • Posts: 1825
  • Mustachian-ish in Live Music Capital of the World
Re: Insurance denying to cover surgery: What to do?
« Reply #9 on: January 04, 2017, 11:10:46 AM »
Remember that a percentage of the customer service reps you reach will stonewall - they will either give weak inaccurate explanations because they don't know the real answer, or they will make an honest mistake and stick to it even though you point out the inconsistency/impossibility of what they're telling you.  As everyone says, persist - call other reps, insist documentation be sent to you, request explanation from supervisors; learn their documentation system if necessary because you may have to figure out the error yourself even though it ought to be their job.

In a previous iteration of the system (1990s or early 2000s) I was billed $540 for a small preventive procedure that I had been told would be covered by insurance.  Numerous requests for clarification eventually revealed that the hospital billed $600 for a procedure that normally costs $60; insurance paid the $60 and had the additional $540 passed on to me by a third party.  Obviously someone made a typo and the insurance company passed the buck instead of challenging the charge.  Internal organization of the hospital company meant that the hospital and company were separate entities, so I dealt with four parties.  No one ever acknowledged causing the error.  At the end of two years of phone calls and written letters (on painfully slow paper because "it's medical, we can't email"), I declared victory when I stopped getting billing letters and the thing was not on my credit score.  I suspect one of the four internally corrected the error or wrote off the "loss", but never told me.

Rimu05

  • Stubble
  • **
  • Posts: 227
Re: Insurance denying to cover surgery: What to do?
« Reply #10 on: January 04, 2017, 11:24:49 AM »
Thank you all for the advise, I did not know this was somewhat common. I will call the hospital today first as I see that my insurance has put in a note that they are awaiting documentation from the hospital. Once I call the hospital, I will await to see if they've submitted everything and then call the insurance company. Once all that is settled, I'll see what is happening.

I'm a red panda

  • Walrus Stache
  • *******
  • Posts: 8011
  • Location: United States
Re: Insurance denying to cover surgery: What to do?
« Reply #11 on: January 04, 2017, 11:40:53 AM »
Thank you all for the advise, I did not know this was somewhat common. I will call the hospital today first as I see that my insurance has put in a note that they are awaiting documentation from the hospital. Once I call the hospital, I will await to see if they've submitted everything and then call the insurance company. Once all that is settled, I'll see what is happening.

Oh, if they are waiting documentation, then you likely will be covered. That's happened a few times for me. It just takes a bit longer to get it all processed.  I wish the EOB would say that instead of just that it isn't covered!

merula

  • Handlebar Stache
  • *****
  • Posts: 1278
Re: Insurance denying to cover surgery: What to do?
« Reply #12 on: January 04, 2017, 11:48:36 AM »
Yeah, that's really good news. BCBS never waits to send a bill and most of the ones I get are changed after-the-fact for things like this.

If you do have issues with the billing department of the hospital, ask if they have a "patient advocate". That's a common term for a role that can help sort these things out. Sometimes the billing reps are... not helpful.

katscratch

  • Handlebar Stache
  • *****
  • Posts: 1326
  • Location: Minnesota
Re: Insurance denying to cover surgery: What to do?
« Reply #13 on: January 04, 2017, 02:40:43 PM »
Thank you all for the advise, I did not know this was somewhat common. I will call the hospital today first as I see that my insurance has put in a note that they are awaiting documentation from the hospital. Once I call the hospital, I will await to see if they've submitted everything and then call the insurance company. Once all that is settled, I'll see what is happening.

Oh, yep -- I read my insurance Explanation of Benefits but I always wait for the actual hospital bill to come before I worry -- like others said, there's usually a lag between everything being submitted and getting the bill after insurance pays their portion.

Fuzz

  • Bristles
  • ***
  • Posts: 337
Re: Insurance denying to cover surgery: What to do?
« Reply #14 on: January 04, 2017, 06:16:04 PM »
Get as much as you can in writing. If you call, take meticulous notes. At some point, if they deny coverage, find a "first party bad faith" attorney to deal with it.

Do not expect them to treat you fairly. You're being naive.

alsoknownasDean

  • Handlebar Stache
  • *****
  • Posts: 2010
  • Age: 35
  • Location: Melbourne, Australia
Re: Insurance denying to cover surgery: What to do?
« Reply #15 on: January 04, 2017, 06:45:28 PM »
Is there a health insurance ombudsman that could assist with this?

Miss Piggy

  • Handlebar Stache
  • *****
  • Posts: 1325
Re: Insurance denying to cover surgery: What to do?
« Reply #16 on: January 04, 2017, 07:13:01 PM »
Ditto what everyone else has said...and I'll add: Don't wait. I made the mistake of waiting too long (more than 60 days) to call about a $75 medical bill. The hospital made a change to the coding and resubmitted it, but the agent also mentioned that since it's more than 60 days old, the insurance company may still deny it.

ZiziPB

  • Magnum Stache
  • ******
  • Posts: 3274
  • Location: The Other Side
Re: Insurance denying to cover surgery: What to do?
« Reply #17 on: January 04, 2017, 07:14:13 PM »
Call the hospital and call the insurance company.  Most likely it's some kind of an administrative snafu. 

My daughter saw a doctor and had some tests done over the summer.  I got billed for the full amount because the insurance company denied the claims.  When I called the insurance company they said that they needed to confirm that she didn't have any other coverage (she didn't, she's been under my policy for over 6 years now, so no idea why this was an issue all of a sudden!).  I said no, they reprocessed the claims and covered it all. 

Jakejake

  • Pencil Stache
  • ****
  • Posts: 716
  • FIRE: June 17, 2016
Re: Insurance denying to cover surgery: What to do?
« Reply #18 on: January 04, 2017, 07:32:47 PM »
My dad just went through having rehab after heart surgery denied a few months ago - and it turned out to be a code error on a form. I went through being double billed incorrectly by my dentist, and it turned out to be an issue with my husband paying my bill - but it showing up as a credit on his dental account instead of mine.

I know straightening this kind of mix-up is incredibly stressful and frustrating and it may take a few hours of phone calls to sort out. But in the back of your head, you can have a secret motivational coach reminding you that you will get very few opportunities in life to earn 5 or 10 thousand dollars an hour.

Papa bear

  • Handlebar Stache
  • *****
  • Posts: 1199
  • Location: Ohio
Re: Insurance denying to cover surgery: What to do?
« Reply #19 on: January 04, 2017, 07:41:50 PM »
All great advice so far.  You should also call and talk to the case manager that handles denials.  They may be able to help as well.

And DO NOT pay for anything yet.  Even if worst case scenario, everything is negotiable.


Sent from my iPhone using Tapatalk

Livingthedream55

  • Bristles
  • ***
  • Posts: 499
  • Location: Massachusetts, USA
Re: Insurance denying to cover surgery: What to do?
« Reply #20 on: January 05, 2017, 08:12:10 AM »
Contact your state Attorney General's Office consumer protection division. They will mediate for you for free. Most have online complaint form capacity and all have telephone access. I did this in my state and they resolved the problem.

Bicycle_B

  • Handlebar Stache
  • *****
  • Posts: 1825
  • Mustachian-ish in Live Music Capital of the World
Re: Insurance denying to cover surgery: What to do?
« Reply #21 on: January 05, 2017, 08:30:40 AM »
All great advice so far.  You should also call and talk to the case manager that handles denials.  They may be able to help as well.

And DO NOT pay for anything yet.  Even if worst case scenario, everything is negotiable.


Sent from my iPhone using Tapatalk

Papa Bear makes a great point! 

Tons of medical bills never get paid at all.  You have lots of negotiating leverage just by being determined.  And if they threaten your credit rating, notify all credit agencies that the biller is in error and you are disputing.  That will give you a method for cleaning up your credit rating if it gets affected.  Don't pay if they are in the wrong.

bacchi

  • Magnum Stache
  • ******
  • Posts: 3922
Re: Insurance denying to cover surgery: What to do?
« Reply #22 on: January 05, 2017, 10:07:26 AM »
Tons of medical bills never get paid at all.  You have lots of negotiating leverage just by being determined.  And if they threaten your credit rating, notify all credit agencies that the biller is in error and you are disputing. That will give you a method for cleaning up your credit rating if it gets affected.  Don't pay if they are in the wrong.

And apply for the Chase Sapphire Reserve before your credit potentially takes a hit.

Abe

  • Handlebar Stache
  • *****
  • Posts: 1264
Re: Insurance denying to cover surgery: What to do?
« Reply #23 on: January 05, 2017, 07:21:03 PM »
Relax.
1) They'll cover the surgery bill, this is a routine, non-elective operation.
2) As others said there's probably some form or something they're waiting for.
3) Also as others said, unless a bill is sent to you, you don't owe anything yet.
4) Hospitals will almost certainly negotiate a lower amount. The $43k is the bullshit high number they throw out to the insurance companies to counter their bullshit low-ball $100 number until they settle somewhere in the middle. I swear it's like buying fish at the dock circa 1880. No one with insurance actually pays anything close to $43k for an appendectomy.