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Insurance nightmare
Well as though the stress from continuing to go downhill with no diagnosis isn't enough, now I'm having trouble with my insurance company.
They require preauthorization and a $75 copay for MRIs. So when I had both the brain and c-spine done, the doctor's office assured me that all of this would be taken care of when they arranged my appointments. I waited weeks to get a date and time to show up both times. When they called with the appointment, they said everything was taken care of; all I had to do was show up, pay my copay and have the MRI.
Well, now I'm getting notices from my insurance company that the claims have been rejected and that I will have to pay the entire amount - which ads up to about $10,000 total. How can this be the case if the doctor's office did their job and took care of the preauthorization like they said they did? Now I can't even get the girl at the doctor's office who handles this stuff to return my phone calls.
Have any of you ever had a problem like this? I sure hope I can get it resolved. I don't have that kind of money to fork out, and I'm facing more testing.
Seems like it never ends.
Cass
They require preauthorization and a $75 copay for MRIs. So when I had both the brain and c-spine done, the doctor's office assured me that all of this would be taken care of when they arranged my appointments. I waited weeks to get a date and time to show up both times. When they called with the appointment, they said everything was taken care of; all I had to do was show up, pay my copay and have the MRI.
Well, now I'm getting notices from my insurance company that the claims have been rejected and that I will have to pay the entire amount - which ads up to about $10,000 total. How can this be the case if the doctor's office did their job and took care of the preauthorization like they said they did? Now I can't even get the girl at the doctor's office who handles this stuff to return my phone calls.
Have any of you ever had a problem like this? I sure hope I can get it resolved. I don't have that kind of money to fork out, and I'm facing more testing.
Seems like it never ends.
Cass
Thanks Quix - in hindsight, I wish I had asked to see everything in print...
They told me all I had to do was show up. Major lesson learned not to trust that things like this are taken care of.
They told me all I had to do was show up. Major lesson learned not to trust that things like this are taken care of.
This is my gut feeling. the place that did the imaging screwed up, either by losing your pre-auth or by not doing it. I suspect that they have a person that assures ALL procedures are pre-authorized. That is that person's job - often their only job.
If they take the responsibility for obtaining the pre-auth for their other patients, they have the responsibility for you, too. I realize that you signed something that gives you ultimate responsibility, but you have some leverage against them if they didn't do for you what they do for everybody else.
You might talk to the office adminisrator and ask who handles this (as if you don't know). They also need to do do an internal investigation. If this person didn't do her job she places the doctor's office is a bad light.
Wherever the imaging was done (hospital, private imaging center) should also have checked for insurance coverage. It behooves them to do so if they want payment. Man, I have been held up for an hour or more while the center has verified that pre-auth was obtained. Did someone there drop the ball, too? They need to check and see why they went ahead with such an expensive test without checking on this.
Document everything that was said to you about the MRI and obtaining pre-auth. Write it all down. I know this is a royal hassle when you feel bad, but a well-put-together complaint can move mountains. It also may be cause for you to change doctors - you can tell them or to report them to JCAHC (Joint Council on the Accreditation of Hospitals and Clinics) for making assurances that were not kept.
You can also appeal the insurance companies decision by making them state whether or not they would have authorized the test given your problems. They have the contract law on their side, but you can make nasty noises at them and sometimes they will rollover. At very least you can threaten to make this kind of thing public. Health Care coverage is a hot topic right now.
Just some ideas. At this point you should be dealing with the bosses of those that were supposed to assure that pre-auth was obtained.
I hope it works out for you.
Quix
You do have some recourse.
Of course, in the end we should all check on this stuff ourselves. At least, when you go in for the test, assure that they have documentation of the pre-authorization right their in from of them. If they don't, but someone promises they have it, get it in writing and get the person's name.
I am far too lax in all this. But, the subsequent bills can break us.
If they take the responsibility for obtaining the pre-auth for their other patients, they have the responsibility for you, too. I realize that you signed something that gives you ultimate responsibility, but you have some leverage against them if they didn't do for you what they do for everybody else.
You might talk to the office adminisrator and ask who handles this (as if you don't know). They also need to do do an internal investigation. If this person didn't do her job she places the doctor's office is a bad light.
Wherever the imaging was done (hospital, private imaging center) should also have checked for insurance coverage. It behooves them to do so if they want payment. Man, I have been held up for an hour or more while the center has verified that pre-auth was obtained. Did someone there drop the ball, too? They need to check and see why they went ahead with such an expensive test without checking on this.
Document everything that was said to you about the MRI and obtaining pre-auth. Write it all down. I know this is a royal hassle when you feel bad, but a well-put-together complaint can move mountains. It also may be cause for you to change doctors - you can tell them or to report them to JCAHC (Joint Council on the Accreditation of Hospitals and Clinics) for making assurances that were not kept.
You can also appeal the insurance companies decision by making them state whether or not they would have authorized the test given your problems. They have the contract law on their side, but you can make nasty noises at them and sometimes they will rollover. At very least you can threaten to make this kind of thing public. Health Care coverage is a hot topic right now.
Just some ideas. At this point you should be dealing with the bosses of those that were supposed to assure that pre-auth was obtained.
I hope it works out for you.
Quix
You do have some recourse.
Of course, in the end we should all check on this stuff ourselves. At least, when you go in for the test, assure that they have documentation of the pre-authorization right their in from of them. If they don't, but someone promises they have it, get it in writing and get the person's name.
I am far too lax in all this. But, the subsequent bills can break us.
Thank you all for the great advice. I did contact the insurance company, and they said they will investigate...Hopefully I can get it ironed out.
I'm going thru the same thing right now! My insurance co covered my spine MRI but not the brain MRI due to a "pre-existing condition." I had my neuro send me my records and I'm writing a letter to the ins co asking for a review. Mine was also pre-authorized. This has been going on for 4 months and I agree, it's a total nightmare. I'm only facing $367 but I'll be darned if I pay it! That's why I pay for insurance!
AMEN! Always talk to the insurance company yourself.
A provider may obtain preauthorization for a procedure. Apparently, that only gives the OK to do the procedure. It gives no guarantee of what the insurance company will cover or what you will be required to pay.
When I was being scheduled for my LP, the office said they would take care of the preauthorization. Then they told me the insurance company said a pre-cert wasn't needed and I could schedule it wherever I wanted. That sent off bells and whistles so I called the customer rep myself.
I was told that it was true that no pre-cert was needed and I could schedule wherever I wanted. Only catch was that the hospitals I could choose from would offer different coverage (3 tiers of payment coverage). The one covered at 100% was also the furthest away and required scheduling gymnastics. I had to choose my poison - convenience or cost.
It's worst since 2010 is here. I may be able to afford some outpatient service co-pays to receive care in my community. But any inpatient care or surgery will need to be done at a hospital where none of my present docs have privileges. Otherwise I'm required to pay a hefty deductible plus 10% and that can add up way too fast.
I hope someone will listen up and help you figure this out. No way you should have to pay the entire unadjusted bill.
Mary
A provider may obtain preauthorization for a procedure. Apparently, that only gives the OK to do the procedure. It gives no guarantee of what the insurance company will cover or what you will be required to pay.
When I was being scheduled for my LP, the office said they would take care of the preauthorization. Then they told me the insurance company said a pre-cert wasn't needed and I could schedule it wherever I wanted. That sent off bells and whistles so I called the customer rep myself.
I was told that it was true that no pre-cert was needed and I could schedule wherever I wanted. Only catch was that the hospitals I could choose from would offer different coverage (3 tiers of payment coverage). The one covered at 100% was also the furthest away and required scheduling gymnastics. I had to choose my poison - convenience or cost.
It's worst since 2010 is here. I may be able to afford some outpatient service co-pays to receive care in my community. But any inpatient care or surgery will need to be done at a hospital where none of my present docs have privileges. Otherwise I'm required to pay a hefty deductible plus 10% and that can add up way too fast.
I hope someone will listen up and help you figure this out. No way you should have to pay the entire unadjusted bill.
Mary
To Cass,
I am currently a nurse in a family practice office and have worked in insurance prior to that.
1-The facility doing the tests would nopt have done them without prior auth. The facilities that I deal with want PA numbers, names and dates that I have talked to insurance companies.
2-Your doctors office should document EVERYTHING in your chart. When who and what was said including the PA number. Get a copy of your chart notes.
3-Today almost if no all facilities have financial assistance of some kind, and no one should be to proud to accept that help. With the prices we get charges compared to the cost to do what they do, they still make money on us!! Not to mention in the end they are getting tasx write-offs for the financial assistance and they look good in the community for offering it.
4-I agree with the others-YOU call your insurance company to ensure these things are done and get the info from your physician, who they taked to, PA number, date and time of calls. Just to ease your mind. As a patient you should NOT have to worry about that stuff, but not everyone cares anymore.
Hope it all works out for you!
Debbie
I am currently a nurse in a family practice office and have worked in insurance prior to that.
1-The facility doing the tests would nopt have done them without prior auth. The facilities that I deal with want PA numbers, names and dates that I have talked to insurance companies.
2-Your doctors office should document EVERYTHING in your chart. When who and what was said including the PA number. Get a copy of your chart notes.
3-Today almost if no all facilities have financial assistance of some kind, and no one should be to proud to accept that help. With the prices we get charges compared to the cost to do what they do, they still make money on us!! Not to mention in the end they are getting tasx write-offs for the financial assistance and they look good in the community for offering it.
4-I agree with the others-YOU call your insurance company to ensure these things are done and get the info from your physician, who they taked to, PA number, date and time of calls. Just to ease your mind. As a patient you should NOT have to worry about that stuff, but not everyone cares anymore.
Hope it all works out for you!
Debbie
Oh, and before your future tests, check with the insurance company yourself to make sure the preauthorization has gone through.
Sometimes paperwork gets lost from one worker to the next; someone thinks someone else took care of it. Either that, or they're just plain incompetent! Hopefully you can get this all worked out.
Kathy
Sometimes paperwork gets lost from one worker to the next; someone thinks someone else took care of it. Either that, or they're just plain incompetent! Hopefully you can get this all worked out.
Kathy
Have you talked to the insurance company? Maybe they just misplaced the preauthorization, or there might be a record of correspondence between your doctor's office and your insurance company.
The closest I've been to this situation was when I went in for a hip injection. I called my insurance company to make sure it was covered without a hospital copay, since I could have had it done at a doctor's office where I had never had any extra charges for injections under fluoroscopy. I was assured that there would be no extra charge, so I had the hip injection.
Before long, I got a bill from the facility where I had it done; I owed a $100 surgical copay. I called the insurance company and was told that the facility where I had it done charged that fee, since I had sedation and fluoroscopy. I repeated my prior conversation with their customer service rep, even telling his name and date of the conversation. I've learned to take notes.
They told me I'd have to pay, but they would look into my "story". Not too long after, I got a call saying they were writing off the charges since they had listened to the recording of my conversation with the first customer service rep, and he had indeed told me that I would have no extra charges.
That doesn't exactly help in this situation, but points out that you should call the insurance company if you haven't already. Tell them that the doctor's office had assured you that the preauthorization was taken care of, and that you would not have had the MRIs if that weren't the case.
It can't hurt, and might help.
Good luck,
Kathy
The closest I've been to this situation was when I went in for a hip injection. I called my insurance company to make sure it was covered without a hospital copay, since I could have had it done at a doctor's office where I had never had any extra charges for injections under fluoroscopy. I was assured that there would be no extra charge, so I had the hip injection.
Before long, I got a bill from the facility where I had it done; I owed a $100 surgical copay. I called the insurance company and was told that the facility where I had it done charged that fee, since I had sedation and fluoroscopy. I repeated my prior conversation with their customer service rep, even telling his name and date of the conversation. I've learned to take notes.
They told me I'd have to pay, but they would look into my "story". Not too long after, I got a call saying they were writing off the charges since they had listened to the recording of my conversation with the first customer service rep, and he had indeed told me that I would have no extra charges.
That doesn't exactly help in this situation, but points out that you should call the insurance company if you haven't already. Tell them that the doctor's office had assured you that the preauthorization was taken care of, and that you would not have had the MRIs if that weren't the case.
It can't hurt, and might help.
Good luck,
Kathy
I did not have the money to get any doctors apoointments or mris or blood tests or anything! I also however did not insurance tho. You might want to check in with the finiacial counseler in the doctors you go to. Mine had a plan ( charity care) who payed for everything for 3 months and 3 months before and you could just sign up again if you needed to get more stuff down after those 3 months.
I'm no longer on that cause i got insurance finally but im pretty sure even tho i have insurnace if the company dont cover it then they would help me out. Also my doctors would give me a 70 percent discount when i didnt have either wich was very nice of them.
Also your doctors office said you were approved? Well OMG i would be flippin my lid at them for that one. It is there fault and you wouldnt of got the tests done if they said it wasnt till you found a new way. You probaly could fight them about that but that would more an likley take to much time and energy.
you should check and see if they have financial counseling there I hope they do for you and you figure this all out
I'm no longer on that cause i got insurance finally but im pretty sure even tho i have insurnace if the company dont cover it then they would help me out. Also my doctors would give me a 70 percent discount when i didnt have either wich was very nice of them.
Also your doctors office said you were approved? Well OMG i would be flippin my lid at them for that one. It is there fault and you wouldnt of got the tests done if they said it wasnt till you found a new way. You probaly could fight them about that but that would more an likley take to much time and energy.
you should check and see if they have financial counseling there I hope they do for you and you figure this all out
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