ins. refusal/topping my day off

[linda/IL]

Got the 2nd refusal to pay a specific MRI Brian had done in March.  I already took it to the nurse who resubmitted and now this headache.  If it was a $500 bill I would be ticked but not as much as this as it is almost $2700 and we pay a very hefty premium to boot.  (Blue cross/blue shield) 

On top of this we got a message in his patient portal today about his appointments next week.  Surgeon 15 min., oncologist 30 min., radiologist 90 min.  We slightly discussed (they didn't know what treatment would be used) last week, and asked if we could go locally.  They said very possibly.  So the 90 min. for radiology is depressing.  Brings into focus the seriousness of the whole thing.  And I have been suffering with migraines & neck/head pain again. 

Plus I cannot get into my mom's internet banking - need another password - and they aren't open this afternoon.  Grrrr.

AND my Quicken account won't open-I made a really big mistake buying this computer.  Nothing but trouble & extra $$ to fix every time I turn around.  Guess I will write checks for her bills.  Want them off my desk today.

[Kay/NC]

Have you been given a specific reason for the refusal? We had almost $14,000 of zjenna's bill when she was fifteen, second viral meningitus bout, refused. They paid for the second hospital, but refused the entire several days at the first one, where we had her transported from to the tesching one at MCV.

They ended up telling me to ask for a " preauthorization after the fact", because her condition was proven so grave, waiting for preauthorization could have killed her. One doctor wrote the letter documenting that fact...they ebdee up paying all but a few hundred $$.

Once I learned the language and the way to rectify it, things were a snap.

Hope you feel better. Fair getting by, plus having a happy 22-year-old helper, should lighten your load!

[mike se il]

Linda,  I've been away from this forum for a while so I've lost track of what folks have going on.  But never ever give up when deaing with an insurance company.

25 or so years ago we had a run in with a company I won't dignify by naming. My daughter put her arm through a window on a door and required some immediate surgery.  The company declined ALL our claims.  We later found out they always denied the first claim.  If a client appealed they would start paying some of it. But they started pulling things like "usual and customary" and not pre-approved.  They would ask for doctor's files and then either not get them or lose them. In fact, when I first read Grisham's "The Rainmaker" I wondered if it was based on our company.

As Kay said, sometimes you just have to word things the way they want to hear it.  Sometmes you have to jump through a ridiculus hoop they have set up.  But always appeal any claim that is denied. And never give up.

[Kay/NC]

Mike, we have all had " that company", at least once in our lives. Mine was state employees' coverage in NC, with claims managed by BCBS. I got to theoint that I would call, get a relresentative, and ask them to please just educate me on what was wrong woth this particular claim.

In .jenna's bout with meningitus, theyaid every cent of the second hospital, but completely rejected the first one, which was the bigger - $13,600 comlared to $6000 sticks in my mind - of the two. Both were out of state, but that was where our doctirs were, and the i surance had akways made remittances for office visits, etc. it was just totally illogical to me.
The rep who finally gave me the cue I needed expkained that the preauthorization fkr the first hospital was not done. Her ER and then admission there were on a holiday weekend, and were true emergency events...so?!?!?

This kind lady informed me of the " preauthorization after the fact" process...if there is a greater " non sequiter" in the English language, I cannot imagine what it would be. All if this took place before I had to initiate any appeals process...that is a legal step in the contract with the company, and it triggers all sorts of arbirptrary deadlines and they have a huge staff designed to deal with thrm all, whereas we consumers are out in the wikds, trying to live our lives and take care of our sick.

Linda is very intelligent, and can make the kind of call that needs to be made, ask what pueces of the puzzle are yet to fall in place. For us, it was getting a letter from Jenna's neurologist at the first hospital, saying that her condition on arrival was auite grave, due to dehydration...that moving her to another hospital in NC would have likely killed her. She got THAT sick overnight.

Meanwhile, even though we could afford to write the check, I was determined to access the benefits I H
had paid fir, which were necessary and proper expenses. I called the financial director of the hospital, and informed him that the clsims would eventually bevpaid, one way or the other, but I had to exhaust my appeals, if the first avenue didn't work, before I could write the check, in my mind.

I explained that the insurance rep had told me I needed the preauthoruzation after the fact, and the doctir's letter was a necessary e,ement of that process. He saw that it got done that day. I had my written request in the mail within a couple if days, and the compsny paid all but a little over $800 within a few days after that. ( BTW, srnd all mail with services...I use certified, return receipt for EVERYTHING of this magnitude).

The timeframe this all took was from New Year's Eve, when .jenna was stricken, until right after her sixteenth birthday on May 6th...so there is your reference. I took the rest of the money we would jave paid for the bill we didn't owe, and put it towards her first car. It covered most of a brandnew Honda Accord back then!

Also, just to say, my family attorney taught me this: Until you pay a biill, the money is YOUR money. He advised me not to pay a cent, until the issue and any possible appeals ran their course. We never had to appeal, but we had a better, faster option. Once you pay a bill, even if you didn't legally owe it, it is THEIR money, and they will make you pay hell to get it back.

This is a big, broken system. I have talked to parents eho actually struggled to lay for n emetgency apoendectomy, when all they had to do was learn the process and play the game...this is what providers count on, and insurance compsnies will gladly let you do.

I refuse to be their sucker. I once paid for our son's hearing aid, i full. The hospital got 90% in an check from Travelers, and n didn't tell me...there was no " bill" to make a credit to, they claimed. I had the EOB from the insurer, but the hospital claimed for months it couldn't find the mo ey...I sent EOB copies and called and called.

Funny, but the say they found it finally, I called and was being given the same runaroubd. I told that rep that she had five minutes to find it...because my next call was to the Attorney Geberal's office, she found it in about two.

Don't start me on the bills from Jenna's last ER stop. The hospital broke the law about five different ways within a week of that day. I let thrm know, in a voicemail, that I knew. Suddenly, the bill went from over $22,000 to about $6000 to less than $500, which was her ER copay.

It is an obscene situation. Obamacare only made it worse.

[linda/IL]

I am back at it with this after getting the fair off our plates.  The decial code  was "experimental procedure not covered".  I slightly blame the surgeon as I know he does a lot of studies on brain tumors and  has a very high ratingas a center for this.  However, if the insurance won't pay for it they may be out of luck.  I do not like to renig on bills but Brian cannot afford this and I'm not happy to back the hospital up for their experiments.

The nurse already sent one letter to Blue Cross already thus this latest refusel.  I just sent a message via internet to the nurse again.  $3000 is on top of the other payments for our out of pocket costs let alone the expense of the trips & hotel bills.  I have been more than satisfied with whole thing but not with this bill.  So much for me sitting on the phone to make sure it was precertified.