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Posted 2/28/2014 3:40 AM (GMT 0)
Please help! I need advice. I am scheduled for surgery on Monday. I just received a letter from my insurance company telling me that they will only pay for 3 days in the hospital?? My surgeon said I would be 5-7. I don't understand this. I have a very low deductible at 450.00. Three days?? I know I won't be out in three days. Does the remainder become my expense? My maximum out of pocket is 2500.00 for the year. The letter was printed on February 24th. It was in today's mail. Nobody from my surgeons office contacted me.
Posted 2/28/2014 4:26 AM (GMT 0)
What you do now is call your surgeon and complain. They will get on the phone with the insurance company and argue on your behalf. sigh. I wish it didn't have to be this way.
Posted 2/28/2014 4:35 AM (GMT 0)
My suggestion is the same. Call first thing in the a.m. It is likely a coding issue. The surgeon likely didn't put additional codes explaininng the extent of the surgery.
Also unless you are comfortable picking up the extra days, be cautious going forward without insurance approval.
Posted 2/28/2014 7:06 AM (GMT 0)
Sometimes they only approve 3 to begin with and if after 3 days in the hospital the doc says you need more time they will call. Last time I was in the hospital I was only approved for 2 to start with and when my doc knew I would still have to stay they called and I was given another week, but only stayed 3 more days.
Posted 2/28/2014 12:04 PM (GMT 0)
this is pretty common practice from insurance companies. every surgery/hospital stay i have had (3 in the last 4 years) the inital "approval" was always less than the final days I stayed. The hospitals are usually good at getting the insurance company what they need to keep the stay covered since they want to get paid.
Posted 2/28/2014 1:10 PM (GMT 0)
This falls under Utilization Review.  There are guidelines for every diagnosis and procedure that have the expected number of days IP for that particular thing.  The approval is set at that amount.  These guidelines are not just set by the insurance company, but there are standard Length of Stay (LOS) tables from medical professionals.

Utilization Review includes Concurrent review...this is where the insurance companies RN case manager calls the hospital and/or doc and they discuss an update of your status, complications, additional procedures, and other issues that may extend your stay.  This is done while you are in the hospital.  I actually have been released in less than the projected days in the past and the RN called after I was already released----that was a shock to me.

Yes, I work for an insurance company, but I will neither villify nor defend them as they all are different.

PS...you can always call your insurance company to talk to a Nurse Case Manager.  You can give them more information on your particular situation.  Just know that they will call and check on you too.  This can be a good thing for those that don't have a doctor who is guiding them through their choices especially if you have a good case manager.  Sometimes I have found them just intrusive and I am pretty self sufficient.  It all depends on your needs.

 

Posted 2/28/2014 4:29 PM (GMT 0)
Hi. Best wishes for your surgery.
My daughter had surgery in July and I was shocked when the insurance nurse called and said she was approved for 3 days when the surgeon was saying 5-6. What happened, and you can check with the dr and hospital, is what others have said here that it is the initial approval and then she would get approved for the additional days. FYI, It turned out that she stayed 9 days and the insurance tried to say I was responsible for the additional 3 days, after the 6, that the hospital did not make an additional call for approval. I told them I would not be responsible because I had made my call to the insurance, as our plan said, after she was admitted, so it wasn't my fault the hospital didn't do there part. Eventually the ins. settled it with the hospital.
Posted 3/1/2014 8:35 PM (GMT 0)
Thanks for the information all. It turned out that because my employer is out of California, so is our insurance. They said he wasn't in network because my surgeon's office in Anthem BCBS' database had a Pennsylvania address. It didn't match with where he is now. The lady from BCBS said it was probably for that reason. She was unable to put the override in. It makes perfect sense now. My surgeon has never operated on anyone with Anthem BCBS insurance before. They had his old location address when he was working at a different hospital. What a relief!

Now I just need to calm my nerves about the procedure...
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