Dr performed surgery deemed "investigative". Insurance Denied. Now what?

[frostedpink]

Long story short, I was hospitalized. The doctor performed a surgery that the insurance company deems "investigative" and so they have denied that portion of the claim (that specific procedure code). Now what? The surgery is done, I was not warned ahead of time that insurance wouldn't cover it. It was a necessary surgery (a stent in my neck). But the procedure code is clearly defined as investigative by the FDA, so I'm confused why the doctor even did this procedure to begin with if they know most insurances won't cover it.
Shouldn't the hospital have checked first if it was an approved procedure? Or should I have been warned that it may not be covered?
I called the insurance company and they said the hospital billing department can do a "procedure code review". Will they automatically do that? And what if it's still the correct procedure? Now I'll be stuck with a huge bill?

 

[yoopermom]

I posted a similar query just a few minutes ago. All I can tell you, from (bad) experience, is that unless your surgery is deemed an "emergency" it is really on YOU to find out ahead of time what will and won't be covered. I am surprised tht your dr/hospital was willing to do the surgery without an insurance preauthorization (simply to make sure that they were going to get paid, since it's a lot easier for them to get $$ from the insurance than from you).

All I can say is start documenting NOW, names/dates/exactly what is discussed, and try to get written confirmation of what is discussed, if possible. Stay on top of things, and don't expect the dr/hospital/insurance to do so. You can definitely ask to have your account suspended while the investigation is ongoing, so you don't have to pay yet (although they don't necessarily have to grant it). Don't let the billing department push you into signing or agreeing to anything until everything is resolved.

Best of luck to you.

Terri

 

[SG131]

They don't always check with insurance before doing the surgery. You usually sign papers saying if it's not covered you are responsible and thats enough for them. That being said, MOST of the time, this can be cleared up by the hospital adjusting their billing code and rebilling. Insurance has gotten so picky about how things are coded that this happens a lot. The hospital will not look at the bill unless you call the hospital's billing department and talk to them about the situation. So call them ASAP and good luck!

 

[Keli]

I'm wondering if this procedure was coded correctly by the hospital billing department in the first place. A stent in your neck doesn't sound like an investigative procedure to me? I've got a few stents in my heart because I had blockages. I'm assuming that's why they put stents in your neck as well. I'd call the hospital billing dept and talk to them and see what you can do to get them to review the coding of your procedure. Then they can send a corrected claim to your insurance agency with a different billing code.

 

[DLgal]

Just because a procedure was "needed" doesn't mean it is covered by insurance. You may be out of luck if, in fact, there is no coding error and the procedure done on you is classified as an investigative procedure. As to why doctors would do it? Because their job is to do what is best for the patient, and if that means a procedure that isn't covered, that's what it means.

If you had been told before that the procedure wasn't covered, but you needed it, what would you have done? Most people would say, if it is NEEDED, do it, and we'll figure out how to pay for it.

 

[frostedpink]

The procedure helped prevent a stroke and potentially saved my life. I will definitely appeal the decision if the provider doesn’t try appealing it themselves. I’m not sure if they do that or if it will be all on me. It’s just so frustrating. This is the last thing I want to deal with when trying to recover from my medical event.

 

[DLgal]

The procedure helped prevent a stroke and potentially saved my life. I will definitely appeal the decision if the provider doesn’t try appealing it themselves. I’m not sure if they do that or if it will be all on me. It’s just so frustrating. This is the last thing I want to deal with when trying to recover from my medical event.

It is frustrating, I agree. I hope it was a mistake and everything works out for you.

 

[PlainJane]

The procedure helped prevent a stroke and potentially saved my life. I will definitely appeal the decision if the provider doesn’t try appealing it themselves. I’m not sure if they do that or if it will be all on me. It’s just so frustrating. This is the last thing I want to deal with when trying to recover from my medical event.

Every time I’ve done an appeal I’ve had to call the provider’s billing and have them resend it with updated codes, if there are other codes.

I’ve been denied once (after appeal) because even though a test had been pre-approved, part of it was considered experimental, but the test can’t be done without the experimental part (as far as I know).

It can be a huge headache and I’m sorry you’re dealing with it while trying to recover.

 

[mnrose]

Keep appealing. Most insurance companies will deny as a first response because lots of people give up. Don't give up. If you keep appealing they are likely to change their mine. One of my great frustrations in our current system is there is ZERO penalty of "bad faith" denial of an insurance claim. It costs them NOTHING to deny a claim. The WORST that happens is that they end up paying a claim they never should have denied. GRRRRR.

 

[DebbieB]

About 3 years ago, my Gyn suggested a 3D mammogram because of dense tissue. I had United Healthcare and assumed it would be covered. Nope, they considered it experimental or not medically necessary. Meanwhile it was all over the news how great it was. I tried several contacts, even using my employer’s medical advocate. The State of PA had passed a law that it had be covered. But my employer’s insurance is a National plan and the PA law did not apply. I ended up paying about $150 (the regular part of the mammogram was covered). When the next year came up, I talked to my doctor and she again advised I get it. I was surprised when they paid it. Turns out they approved it in 2017, I guess they got enough grief from women.

 

[low-key]

fight hard, if it dont work, just dont pay, after about a year, they will want to talk, and make a deal

 

[Heidict]

fight hard, if it dont work, just dont pay, after about a year, they will want to talk, and make a deal

And in the meantime, they will likely send her to collections who very well could be reporting to the agencies. If she doesn't care about her credit, not a big deal. Most people these days though want to avoid that.

 

[SharonZ]

At the time, my insurance carrier required that surgery termed elective be performed at a surgery center. I had outpatient hernia repair at the hospital, and my insurance carrier charged me 20% as co-insurance. To alleviate my bill going to a collection agency, I paid the amount in question while I appealed the charge. My surgeon thought the charge was ridiculous and wrote a letter to my insurance carrier stating that he would not have done surgery for me at a surgery center because of my two existing heart conditions. The co-insurance was removed, and my money refunded. If you work at an office, see the HR director. They can put you in touch with your insurance rep.

 

[JustCallMeMommy]

All of my doctors would automatically recode and rebill, but you may want to check with their billing department to be sure.

 

[chicagoshannon]

Contact the billing department and have them recode it. That usually does the trick.

 

[3smithboys]

When my son was in kindergarten, he was taken by helicopter from one hospital to a Children’s hospital because the dr he needed was there. A few months later, I got a bill for over $70,000 for the helicopter ride! They tried to claim it wasn’t medically necessary. I had to fight it- what did they think it was a tourist ride around Philly??? Eventually, they gave in... it was a lot of back and forth and became a “coding mistake.”

 

[mommy2allyandaveri]

You can file a grievance and request that it be covered. I process these exact type of grievances.

Like others have mentioned, just because something is "medically indicated" doesn't mean it will be covered. It is the responsibility of the patient to ask in advance if it's covered and even if covered, what it will cost.

The only surgeries I can think of that aren't covered where I am is related to fertility issues or cosmetic.

 

[OhhBother]

I work in health care. Before you get caught up in appeals and grievances, just call the hospital billing department and explain it needs to be reviewed and recoded. Odds are good that will happen, and this will all be resolved.

You can also ask them to place your account on hold while this is happening so you won’t get sent to collections.