Insurance is balking on covering my last surgery

May not help, but appeal it. Sometimes they deny stuff just to see if we'll accept the denial. If they deny your appeal, have your surgeon write them a letter (s/he should know what to say -- this happens far too often).

Sure hope they change their minds. So aggravating!
frances

Hi Fashiongirl,

I'm sorry to hear about your insurance troubles. I had my fair share of them this year, so I can relate. Did you already have the surgery, or is this for an upcoming surgery? If you already had the surgery, boy, how rotten!

Ask your surgeon if you can see a copy of the appeal letter before they send it in (or better yet, have them send the copy & materials to you & then you yourself submit the appeal to the insurance company). That way you can find out ahead of time whether or not your doctor wrote you a good letter.

During my second appeal, I made the mistake of trusting my doctor to write a good letter (he is a world renowned neurosurgeon, after all) & when I later saw it (after the denial of the second appeal/after exhausting my insurance's internal appeal process, while I was getting together all the paperwork to send my appeal to my state Insurance Commissioner for appeal) I was beyond horrified. It was the worst letter I'd ever seen. It must have taken 30 seconds to write, because it was about 2 lines & said absolutely nothing. I promptly wrote a strong letter to the Insurance Commissioner, detailing my argument, & forwarded a copy to my surgeon & asked him to rewrite his letter, using mine as somewhat of a guide. His second letter was a thousand times better. If I hadn't seen that letter & had continued to let my dr's office handle my appeals, then I doubt that I would have won my case. I can tell you this much, I won't make the same mistake next time.

Skeye

Thanks everyone. Great advice! I had the surgery back in May and thought it was all by the book. But this is the second time this doctor's office has "messed" up something with insurance. A code or something is wrong. I'm making calls in the morning to figure out how to fix this. So stressful and frustrating.

Draka--they did that to you while you had an IV in your arm? Wow. That's just cold!!!

I am glad Frances brought up the Pre-Determination Letter, she is right, it basically is not worth the paper it is written on because in the fine print it states this is not an authorization stating payment will be made. Many times folks misunderstand this. I hope you get this worked out.

I had the exact same thing happen for a procedure I had back in December of last year.  The nerve ablation was denied because it was considered experimental (even though it was pre-approved...as is the policy of the PM practice).  I'm still fighting it because of the pre-approval, but I'm afraid I'm going to be stuck in the long run.  I swear I even called the Dr's office the day before to make certain that I was OK with the pre-approval and they assured me that they NEVER do any procedure without pre-certification and that is why I had to have the "test" procedures (which were covered in full).  I'm kind of waiting on the shoe to fall on this one and to be hit with a serious bill because I'll be done paying the last 2000.00 on the brain MRI I had done at the beginning of January in July.  They would only allow a six month payment plan without a credit application and all that nonsense.  I refuse to apply for credit for a procedure I have already had done....that's insane!!  Of course, I do pay my bills....but a credit app for a hospital....give me a break!

Best to you on this one.  Appeal as quickly as possible in every way.  Make sure to have everything in writing to the insurance company and keep copies.  They tend to give an impossible timeline for dispute and if you don't turn it in by that date, they assume you agree with the decision made.

 

Great advice everyone, thank you! I called the insurance company today to find out what the exact issue was and they couldn't tell me. The letter said it was experimental? It was artho knee surgery for arthritis! My 4th! Not experimental! So I asked if the codes were incorrect. They couldn't tell me. I asked if any of the pre-certification documentation was missing. They couldn't tell me. So all in all, quite useless. So then I called my doctor's office, who received the letter as well, and they never called back. It seems no one cares about this but me. Great!

I'm going to try again tomorrow. Hopefully someone more helpful will be on the phone...

Fashiongirl,

In the denial letter, did they not tell you the reasons for denial? When I've gotten denials in the past, my insurance has always listed their reasoning. I'm surprised that no one was able to tell you why your procedure was denied. Maybe look at the letter again in case you missed something?

I don't envy you at all. I know that this insurance business is a real pain!

Skeye

FG-
Just wanted to encourage you not to get too hung up on the idea that it was labeled "experimental". All that means is that the procedure is not FDA approved for your exact condition. The majority of procedures are only approved for one or two diagnoses, but are widely used to treat other conditions. Even if the surgery has been commonly done to treat your particular condition for decades, it could still be considered "experimental".

The more important indicator is whether or not Medicare covers it. In one case my benefits changed because Medicare decided in the middle of the calendar year that no more than 3 levels of facet injections were beneficial during a single visit. The day before they felt that up to 12 levels of facet injections in one visit could be beneficial. They didn't announce the change. Didn't say anything to patients or doctors, just started denying payment for anything more than 3 shots.

The state chapter of the AMA went up in arms & eventually my insurer (I don't want to give their name, but they're one of the major ones) agreed to send out letters to all in-network providers & to all insureds, and to cover all procedures performed prior to the date of that letter under the old rules.

The whole process is just mystifying. You also might try asking your doctor's billing office what codes were submitted & then call and ask to speak to the benefits/coverage department at your insurer. On occasion I've had better luck with them (usually they know less, but sometimes I've gotten lucky). Also, some insurance companies provide patient advocates. You can call your insurer & ask to be assigned a patient advocate (they may or may not have one). If they offer that service, you give the advocate permission to access all the same things your insurance company can access as well as to talk with your doctor to obtain information. They can't make decisions for you, but they can help straighten out confusion situations & explain them in plain terms. On occasion some large employers have an in-house advocate -- a member of your company's own staff (usually in HR) whose job it is to help employees with benefits issues. If the insurance people can't assign you an advocate, try calling your HR department & ask if they have an advocate who can work with you to straighten things out.

Also, not sure if you had surgery at a surgicenter or an actual hospital. If it was at a hospital, almost every hospital has patient advocates. Some are better than others, but they're free so it's worth a try. Some are volunteers (often those are the best) and others are paid staff. If it was at a doctor's office or a surgicenter, you're probably not going to get any help from them.

Hang in there & keep fighting!
frances

Hang in there & keep fighting!
frances