Insurance Woes . . . . (Full Version)

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isaacsmom -> Insurance Woes . . . . (7/19/2008 10:43:30 PM)

I had a c-section in December, 2006. My hospital, doctor, etc. were all in network. No problems there.

A few months later, after all bills were paid, I received a bill from an anesthesiologist for over $1100. I called because I knew the nurse anesthetist (spelling?) who attended to me in the OR had already been paid. Evidently, there was a second anesthesiologist walking around the OR. He didn't not tend to me, he was just there.

My insurance refuses to pay because they say he was unnecessary.

The hospital says this is their policy, to have a nurse anesthetist and an anesthesiologist supervising. They said they'd appeal to the insurance company. I said "Great, thank you". I didn't hear from them for a year.

I got a bill in the mail today. Same bill. Evidently it's not been resolved. I haven't heard a peep in a YEAR.

I feel I had no choice in the matter, as a patient. How was I to know I needed a checklist while laying on the operating table -- "OK, are you going to get paid by my insurance? How about you? Are you really necessary?" [&:]

What am I to do? I plan to make a phone call to my insurance company first thing Monday morning (which will be exactly 19 whole months to the day after the surgery), to see exactly what happened in the appeals process. Hubby says we'll get an attorney to look at it before we pay it, it just doesn't seem fair.



MrsTracy72 -> RE: Insurance Woes . . . . (7/20/2008 1:08:51 AM)

That is horrible. Definately call your insurance company and also find out what the timelines are for the hospital to bill you. Here they get 12 months, and if they don't do it in that timeframe, they have to eat the bill.

I had that problem with my second pregnancy but it was the lab that was billing. They billed incorrectly in the first place and the insurance paid out only what they had to on the incorrect bill. Then a bit over a year later, they caught their mistake and sent a corrected bill to the insurance company. The insurance company refused to pay because they had already paid on the first bill and too much time had gone by. So the lab put the bill through again but this time with different codes for different tests thinking they would slip it by.

My insurance company caught on and not only denied the bill, but sent me a letter telling me it wasn't my responsibility to pay either because they were already paid according to the bill they sent and their time was up to correct so legally, they had to eat the costs.

It took me 6 months and finally one day I called the hospital's main line, asked the operator for the name and extension of the hospital administrator. I left him a message on his voice mail saying that since the lab was connected to the hospital, I was going to name the hospital in my lawsuit and I needed the correct spelling of his name.

I am not kidding you, but within 5 minutes, I had his secretary calling me back telling me that she was going to deal with the lab, and later that day the lab called me back and told me that they had already sent me out a letter stating that I had a zero balance and that bill had been taken care of.

You just need to make sure you know what your rights are before you do that though. But usually if your insurance doesn't pay for a valid reason, then because the hospital/doc is under contract with the insurance company, they can only bill you according to the contract terms they have with the insurance company. At least that is how it is here.

Good luck!



isaacsmom -> RE: Insurance Woes . . . . (7/20/2008 9:48:23 AM)

quote:

But usually if your insurance doesn't pay for a valid reason, then because the hospital/doc is under contract with the insurance company, they can only bill you according to the contract terms they have with the insurance company. At least that is how it is here.


Interesting! I will definitely check into that.



sisrev -> RE: Insurance Woes . . . . (7/20/2008 10:56:55 AM)

Just an FYI about what the insurance companies call "medial necessity"--it is very common to have a bill from both a nurse anesthetist and a supervising MD anesthesiologist. An MD anesthesiologist can supervise, in some states, up to 4 different CRNAs at a time. The MD and the CRNA are both paid--how much, and what percentage, are often regulated by state insurance laws that vary from state to state.

Same thing on the "not timely filed" denial--insurance regs vary from state to state, so be aware that some states have a time limit for filing medical bills and some do not. You should be able to find a website for your state's Department of Insurance--look under FAQ for patients, and also for providers (which are the medical service providers) to see if it mentions timeliness of filing.



MrsTracy72 -> RE: Insurance Woes . . . . (7/20/2008 4:16:46 PM)

I would first start with the insurance company because you need to find out what is and is not contracted between them and the group of providers who are billing you. They should also be able to tell you what the timeline is for filing a bill with them, or sending out a bill to you.

Your state does have an insurance commissioner and there are people in that office who can walk you through step by step after that. But I personally have never had to go that far with a medical bill that I didn't think was correct. If you do have to do that, once the providers know that you are taking the time to find out what is and is not allowed, they will be way more willing to work with you.

I think that often times, they feel they just send out a bill, people pay with no questions asked. If you know what you are talking about then they tend to take their time with you and work with you.

Also, find out what the contracted payment would have been. In my state, the hospital or provider cannot accept more from you than they do from an insurance company. But like the above post said, different states have different rules. Just do your research and make the phone calls. Stay calm and make sure they know you are contesting the bill because of it being so long ago so they don't say it is a year overdue and send it into collections. You have to do that in writing though and keep a copy for yourself. You don't want that on your credit bureau.

I had a problem with a bill that I should not have gotten and the woman started telling me I was snotty and hollering at her for no reason. My voice never even was raised and while I was a bit short with my answers, it was because she totally did not listen to me and would not let me tell her what I needed to. She just wanted the money no matter what.

I finally got in touch with her manager and through that person and a patient advocate, someone finally listened to me, saw that I was double billed, and then decided to take me seriously. But it wasn't until I went straight back to the doctor about their billing practices that this happened.



isaacsmom -> RE: Insurance Woes . . . . (7/21/2008 10:04:15 AM)

Thank you for your replies. I called my insurance company this morning and asked them what had transpired in the past 13 months (since my last conversation with the anesthesiologists's billing office, when they said they'd appeal). Apparently, there was no appeal. They had 6 months to do so. Hmmmm!! Sounds fishy to me! My insurance company advised me not to pay it and not to be intimidated into paying it. They said this is the only hospital in the network they have problems with in this particular situation. I asked them if when I gave the hospital my insurance information in advance if they should've known only one CRNA/Anesth. would get paid. She said of course. And she said that CRNAs are perfectly capable and qualified to do the job alone, that's why they go to school. (And the CRNA is the only one I remember attending to me anyway, he was great).

[&:]

The insurance company told me to call the billing company and fight it. They said if I am bullied, to stand my ground, then call my insurance company back and THEY will call them. Wow!

So I have a voicemail in to the billing company this morning. Should be an interesting day.

Of course I am going to start off being very nice and polite. [sm=angelic.gif]



isaacsmom -> RE: Insurance Woes . . . . (7/21/2008 1:05:57 PM)

WOW! I got ahold of the billing company, they said since my insurance would only pay for one, the second bill has been removed from patient responsibility, and I'm to disregard the bill I received over the weekend. God is awesome! I had to pray and hand it over to him because messes like that just worry me sick, LOL. [:D][:D]



Ps103 -> RE: Insurance Woes . . . . (7/21/2008 1:08:47 PM)

I am glad it is working out for you--and extra-glad that your insurance company is willing to help you deal with them.

Years ago, a friend of mine had heart surgery to correct a problem she had been born with, but which had not been discovered until she was 40. I am not sure how it is other places, but around here you do not get to choose your anesthesiologist, one is assigned to you. Hers charged $38k--which, btw, was more than the cardiac surgeon charged. The insurance company covered a part of it, but said the fee was many times higher than other anesthesiologists in this area charged for the same thing, and they would not be covering it. Her husband called the doctor's office, certain that the amount was an error, but the billing office said it was correct and admitted they did "get a lot of flack about the amount from patients."[:@] I am not sure how it turned out for them.

Some of these doctors give the good ones a bad name[sm=aside.gif]



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