Author Topic: Denied health insurance claim - what are my options?  (Read 2593 times)

agofi

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Denied health insurance claim - what are my options?
« on: April 27, 2018, 11:20:56 PM »
Hi Folks,

I've a health insurance related question that I'm hoping the collective wisdom of the group can help me with. We moved to US less than a year back and I'm still trying to wrap my head around the insurance system here. So, any or all of my questions maybe noob level. But, I'd sure appreciate your thoughts.

My two year old daughter has had a battery of medical tests over the past year. Her final test(a genetic test called whole exome mapping) provided us with a diagnosis of a very rare disease last week. While we're still trying to find solid ground, today, we received a bill for 27000 USD! Now, before the test was run, the hospital had coordinated with the insurance company to tell us that our liability for this test would be 0 as we've already met all our deductibles for the year. However, as per the communication from the insurance provider, they do not cover investigative procedures and moreover, the lab where the test was performed is not in network. It is obvious to me that there was a communication failure between the hospital and the insurance agency. But, am I mistaken in that assumption?

I intend to get on the phone first thing on Monday with the insurance agency and the hospital to figure out where things went wrong. But, meantime, here are my questions:
- who is responsible here to ensure the lab where a test is conducted is in-network?
- can the hospital, lab or insurance provider be expected to share or pay the full amount? If so, who should I start with?

PS: Thank you for reading this  far. We can foot the bill if we have to. So, this is not a scam / request for donation.

former player

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Re: Denied health insurance claim - what are my options?
« Reply #1 on: April 28, 2018, 02:02:38 AM »
I'm sorry to hear of your daughter's diagnosis, and hope that it provides a way to find good treatments for her.

It sounds to me as though you relied on statements from the hospital and insurance company that this test would be done at no cost to you.  The legal principle you are relying on is called "estoppel": you considered that you had a promise from the hospital and insurance company that this test would be carried out at no cost to you, and relied on that promise.  The entities making that promise can't now go back on it to your detriment.

Now, I don't know what the details are here, and whether they are sufficient for the courts to uphold a claim of estoppel.  I don't want to know, either: the internet is not the place for that detail.  At the moment I think you need to take the stance that you are in a negotiation with these people, and your starting point is "you promised us that this would not cost us anything, you can't now go back on that promise", and take it from there.

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Re: Denied health insurance claim - what are my options?
« Reply #2 on: April 28, 2018, 02:44:17 AM »
Before you do too much freaking out, I'd get on the phone. Stuff like this is often a mistake. Start with the insurance company.  Tell them you had prior authorization, ask them to confirm the codes with the hospital. The hospital may have billed wrong. This has always taken care of it for me.

The next step is to file an appeal. (I've only gotten this far once)

Then I would contact your states insurance commission and or a lawyer. (Never gotten this far)

doneby35

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Re: Denied health insurance claim - what are my options?
« Reply #3 on: April 28, 2018, 10:05:18 AM »
Did you verify with both the hospital and the insurance company that the hospital or lab was in-network? or did the insurance company tell you that it was in-network. I had a case for a foot surgery where the doctor that performed the surgery was in-network but he had scheduled the surgery at an out-of-network facility, luckily i caught that and then told them to change it or else my bill would've been astronomical.

It is usually the patient's responsibility to know. However if the insurance company told you the wrong thing and that it was going to be at $0 cost, then it is their fault and i would start with calling the insurance provider and let them know.

Dave1442397

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Re: Denied health insurance claim - what are my options?
« Reply #4 on: April 28, 2018, 10:17:20 AM »
If you end up in the worst-case scenario and are held responsible for the bill, be aware that $27,000 is a starting point. You should be able to knock at least 40% off that, and they may settle for less if you tell them you can pay it in one lump sum.

Hospital billing systems are very different for people with insurance vs those without insurance. The hospital will submit a bill to an insurance company, who will then come back with what they consider a standard fee for the specific procedure/test, and that's what the hospital will settle for. Look into it if you get to that point.

civil4life

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Re: Denied health insurance claim - what are my options?
« Reply #5 on: April 28, 2018, 10:43:24 AM »
Everything said so far is great information.  I really do not have much to add.  Other than I have had plenty of fights with medical providers and insurance companies.  Hopefully it is a matter of administrative paperwork being changed/corrected.  If not there is the insurance companies internal appeals process.  I am actually doing this right now.  I am trying to get coverage for a provider that is out of network, but it is the only specialist in my area offering the treatment.  For me it is a submittal of a formal appeal with a letter of medical necessity and back up from my doctor.  If an internal appeal is not approved, there is external appeal.  Then as discussed legal options.  However, in that case it is probably cheaper to find out what the negotiated price with the provider will be than legal representation.  Be sure to document all of your actions, who you talk to and when etc.

Good Luck!

Dee18

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Re: Denied health insurance claim - what are my options?
« Reply #6 on: April 28, 2018, 12:05:26 PM »
Two years ago I received a $6000 bill for genetic testing that I had been assured would be covered.  I was quite distraught, but quickly spoke with the genetic counselor. She straightened it out immediately.  I hope your bill is taken care of as quickly and smoothly.

agofi

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Re: Denied health insurance claim - what are my options?
« Reply #7 on: April 28, 2018, 12:31:04 PM »
Did you verify with both the hospital and the insurance company that the hospital or lab was in-network? or did the insurance company tell you that it was in-network. I had a case for a foot surgery where the doctor that performed the surgery was in-network but he had scheduled the surgery at an out-of-network facility, luckily i caught that and then told them to change it or else my bill would've been astronomical.

It is usually the patient's responsibility to know. However if the insurance company told you the wrong thing and that it was going to be at $0 cost, then it is their fault and i would start with calling the insurance provider and let them know.

Unfortunarely, I did not personally verify with the insurance. That's one of my big learnings from this thus far. In the future I'll always enquire what lab is being engaged for testing and verify if the lab is in-network. Our Genetic Counselor did however check with the insurance provider who gave them a 0 dollar estimate. Appreciate the response. I'll be getting on the phone first thing on Monday morning once the insurance office is open.

agofi

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Re: Denied health insurance claim - what are my options?
« Reply #8 on: April 28, 2018, 12:32:20 PM »
If you end up in the worst-case scenario and are held responsible for the bill, be aware that $27,000 is a starting point. You should be able to knock at least 40% off that, and they may settle for less if you tell them you can pay it in one lump sum.

Hospital billing systems are very different for people with insurance vs those without insurance. The hospital will submit a bill to an insurance company, who will then come back with what they consider a standard fee for the specific procedure/test, and that's what the hospital will settle for. Look into it if you get to that point.

Thank you so much! That is some great information. If payment turns out to be our only resort, this information will come in real handy.

frugaliknowit

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Re: Denied health insurance claim - what are my options?
« Reply #9 on: April 28, 2018, 12:40:34 PM »
I think your approach of calling both the insurance company and the billing Administrators at the hospital is a good approach.

About a year ago, as a precaution, I visited the Emergency Room (who btw was not "in network", but in an emergency, that is OK.  The ER called my provider before they did anything and said everything is covered except a $300 co-pay which I gave them) and was given a battery of standard tests for a total bill of around $5,000 (it turned out nothing was seriously wrong with me; just a brush of peripheral vertigo probably due to crystal deposits in my ear canal due to allergies making me dizzy...).

Anyway, this one bill for about $200 kept "not getting paid".  This went on for about 6 months!  I would call the provider, call the hospital (my provider hospital, not the one who ran the test), the hospital would say, "oh, don't pay it, we'll call the provider (lab) and take care of it...blah, blah, blah...".  I continued to receive the bill every month or so, until finally the lab threatened to escalate to a collection agency.

I got on the phone with the insurance co.  They told me to get on the phone with hospital billing (again, my provider hospital, not the emergency hospital).  Hospital billing explained the hospital had an arrangement to do the test at a discounted rate that the provider was not applying.  More phone calls made to the provider.  Followed up again with hospital.  Finally, followed up with lab, who said something like "Special rate applied, balance $0..".  I asked them to send me a statement in writing which they did.  Even though it was not a huge amount of money, what a relief to have that no longer "hanging over my head"...

Assuming you visited the in-network providers, I think if you persist, my guess is, you will be ok.  Contact all parties involved, keep following up.  I sympathize you have to go through this stress, on top of the terrible stress of having your daughter having medical issues!
« Last Edit: April 28, 2018, 12:48:11 PM by frugaliknowit »

neophyte

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Re: Denied health insurance claim - what are my options?
« Reply #10 on: April 28, 2018, 12:43:50 PM »
Many insurance providers do not consider whole exome to be a diagnostic test and instead classify it as a falling under experimental research and won't cover it.  The genetic counselors I've met are pretty aggressive about making sure it'll be covered, so I'm guessing paperwork mix-up somewhere. I'd let your GC know and my guess is she'll probably try to help you get it figured out.

Dee18

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Re: Denied health insurance claim - what are my options?
« Reply #11 on: April 28, 2018, 05:25:31 PM »
Since the genetic counselor gave you the assurance, I would contact him or her before contacting the insurance company.

Trying2bFrugal

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Re: Denied health insurance claim - what are my options?
« Reply #12 on: April 28, 2018, 09:58:23 PM »
1. When issuer going to get claims for surgeries, procedures with>$1000, Pre-authorization is must.
2. It is patient responsibility to call health care insurance company to confirm preauth. Though hospitals do that,  sometimes they naattu not get response in time and assume thatwill be covered. Only thing it will get is what goes in documentation not verbal things. That's how system works to avoid many possibilities.

3. When someone was told it was approved but later denied by insurance, then there could be wrong procedural codes used during claim or preapproval. So best way to know is from letters insurance companies send you or check something called EOB.

4 . After you tried asking the hospital to do the appealing and it didn't get positive reconsideration from insurance,  sometimes the hospital will be lazy and ask you to work with insurance you can request the book keeper or the billing personal on hospital office for re requesting for claim on your behalf. If they won't do, then you call and speak to customer care of insurance.

5. Let's say you ran out of all options,  then you can call the hospital and negotiate the price. It is always better to do upfront as hospital will take 30% -40% of total cost that they quoted. Last week I had to MRI for my wife,  the total billed amount was $5900 ave insurance company paid them only $590 in addition to $75 I paid. So you see the markup or insurance company negotiated price. On Thursday case you may end up losing $5000 if odds aren't favoring you.

On my personal view,
May be if you fail on customer care, lawyer or directly negotiating will make you get some odds. What ever you do,  please don't lose your nerves. Patience is key. I had changed surgery date since hospital told but not don't pre-auth as they told you. But even after got pre-auth, the surgery cost was sent to me to pay for it. After more than a year on appeals they found that'wrong codes' was used. I was lucky to have a rep from hospital who was willing to reach out multiple times to insurance company.

Hope you get it covered

geekette

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Re: Denied health insurance claim - what are my options?
« Reply #13 on: April 28, 2018, 10:12:55 PM »
I had some genetic testing done on a biopsy which resulted in avoiding surgery (yay).  The insurance company denied the test as "not medically necessary" (boo).  My doctor and the company that did the testing sent letters, etc., and it was again denied.  The $4000 bill was reduced to $300, which I happily paid. 

It's surprising how far the bill can come down when it's the individual who has to pay.

pk_aeryn

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Re: Denied health insurance claim - what are my options?
« Reply #14 on: April 28, 2018, 10:19:08 PM »
Another possible option to be aware of: If you get your insurance through your employer, some companies offer a benefit/service where a third party company will (with your written/signed authorization) sort out insurance billing and other issues on your behalf.  I've used this several times when I was double charged for things and the doctors' accounting was virtually unreachable. I was so grateful to not have to spend my own time on hold and calling and calling and calling.

agofi

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Re: Denied health insurance claim - what are my options?
« Reply #15 on: April 30, 2018, 01:52:06 PM »
I got on the phone with the insurance provider, the service provider(the lab) for the genetic test and our Genetic Counselor.

The insurance provider has indicated that they deemed the test to be investigative and not diagnostic(as initially suggested by @neophyte ). They did not have a response to my question of why this was mentioned post the test and not right at the beginning. They will reach out to our Genetic Counselor to evaluate more detailed paperwork and then re-assess if the test was a medical necessity.

Our Genetic Counselor was very helpful(thank you, @Dee18 ). She indicated that the hospital did not personally do the pre-certification. They handed over all the information to the lab who then did Benefits Investigation with the insurance provider. So, I then contacted the lab and they really put our fears to rest. They have assured me that they did a Benefits Investigation prior to the test and that was the 0 dollar amount that was quoted to us by the Genetic Counselor. They'll also stick to this initial assessment that they had done and hence will not bill us. They'll work with the insurance provider to get paid. If an appeal does have to be filed, then they'll ask for our consent and do that on our behalf. So, @pk_aeryn that will save us the hassle of being on call eternally. But, I'll definitely check up in my spouse's employer does have the service you mentioned. And no matter how the conversation between the insurance provider and the lab evolves, given that they promised us a 0 USD bill, that's what they'll stick to.

So, while the matter is far from resolved, we have the assurance that we're not liable to pay any of the amount. And with all the great information in this thread(thank you, @iowajes @former player @civil4life ), I now understand that even if we have to make a payment eventually, we can try to knock off 40-60% of the quoted amount.(thanks, @geekette @Trying2bFrugal @frugaliknowit @Dave1442397 ).

Given my daughter's diagnosis, I know this is the first of several insurance battles we'll have to fight. Going forward, I'll always check up on the pre-authorization / certification on my end, @doneby35 . Thank you, everybody for your generosity with your time and stories! I had an action plan courtesy all your help. Here's sending warm wishes for an early FI for those of you still striving and a fulfilling post-FI life for those of you already there.

mm1970

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Re: Denied health insurance claim - what are my options?
« Reply #16 on: April 30, 2018, 02:08:34 PM »
This will require some phone calls, and it might not be settled quickly.

A little backstory.  Kid #2 born with a (non life-threatening) birth defect that needed to be fixed somewhere around the 9 month to 18 month mark.

As we approached that time, pediatrician referred us to in-network specialist.
In network specialist does not do the surgery anymore, referred us to university hospital.
As part of this process, we got a pre-authorization code for the surgery from my insurance.

Have the surgery.

Get the EOB from my insurance.  "We are covering $0 because this was not an emergency surgery."  Well, no shit.  That's why the pre-auth.

So, we had many phone calls to make to insurance, our home doctor group, and the university hospital.  Some issues:

1.  The pre-auth number had expired, so they had to issue us a new one.
2.  One reason for the pre-auth and the referral is that my insurance company will only pay a bill to the home group.  So...the bill *should* have been sent to the home group to forward to insurance.  Instead it went right from university hospital to insurance.
3.  Still, with phone calls and such, very little got paid.  You see, my child had double coverage from his two parents, but mine was the primary.  So, a small bit was covered by the secondary. 
4.  In the midst of all this, we had open enrollment at work, and lo and behold, I see the "outpatient responsibility" of $125.  We call up the university hospital, and they say "why, you are right!  Let's see what we can do!"  And eventually, they accepted our $125 payment, the paperwork got worked out between the insurance company and our doctor's group.
5.  Lather, rinse, repeat for the surgeon.  I kid you not.  Separate billing.

In the end, the bill was fully paid a full 18 MONTHS after the surgery.  18 months.  Surgery was something like $20,000-25,000.

This was not my first experience with things getting lost "in the middle".  In this case, the doctor home group was the middle man between hospital and insurance.  In a prior instance, there was a "repricing" company that simply LOST my husband's annual physical info for 2 years.  He had to get the actual fax # of the individual at the repricing middleman, and make sure that he got the bill from the doctor.  Then he had to make sure the insurance company got the bill.  By the time it got paid, we weren't even on that insurance anymore.

And then there was my first childbirth...ahhhhh.

I'm very sorry.  Get a notebook.  Write it all down with names and dates.  Try and be patient.

zygote

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Re: Denied health insurance claim - what are my options?
« Reply #17 on: April 30, 2018, 02:24:26 PM »
I'm glad it's on its way to being sorted out, @agofi !

Sometimes I think that hospitals/labs/providers bill the most astronomical amount they can think of just to see what they can get from the insurance companies.

I went to an in network urgent care a few years ago needing three stitches on my face. The admitting doctor didn't want to mess up my face, so she called the on call plastic surgeon. It took him approximately five minutes. The plastic surgeon himself was not in network.

I ended up with a $5000 bill for the three stitches. I called the plastic surgeon's billing office in a panic, and it turns out they had no intention of charging me anything. They just submitted whatever and were happy to take my insurance's $800 out of network reimbursement check as payment in full.

Moral of the story: never, never, never pay the bill that arrives without following up with everyone.

ltt

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Re: Denied health insurance claim - what are my options?
« Reply #18 on: April 30, 2018, 06:24:44 PM »
Our daughter has a rare medical condition which has required many surgeries over the years.  The insurance company always liked to call it investigational and, therefore, didn't want to cover it.