Insurance denial and $22k bill

[Grmnshplvr]

Hoping someone can give me some advice or reassurance here. My daughter was born with a nasal deformity, when she was an infant our ENT said to contact him when she is 16 and done growing to have it fixed. Basically her septum was deviated, but way off, her entire nose was crooked.

She is now 17, we went back to the same ENT and he referred to us to a plastic surgeon that specializes in cleft surgeries because hers was so difficult. The surgeon agreed it should be fixed and told me his office would submit the paperwork to the insurance and not to worry because it was a birth defect and he saw no reason it wouldn't be covered. 2 or 3 weeks later his office calls, we're all set, we set the surgery.

4 weeks post op I get a bill from our insurance for $22k - the denial deemed it was not medically necessary. I called the insurance right away and said the prior authorization had been submitted, we weren't told this would cost us anything out of pocket!! She said the prior authorization was submitted for billing codes 30460 and 30462 and that their response to that was no prior authorization was necessary. Post op it was billed under a completely different code and that was denied. She put me through to an insurance advocate who will appeal the decision on our behalf. I'll hear back in 10-14 days. This bill does NOT include the doctor's bill or even anesthesia, I will be looking at close to $40k and most definitely bankruptcy if this denial holds.

 

[NHdisneylover]

Hoping someone can give me some advice or reassurance here. My daughter was born with a nasal deformity, when she was an infant our ENT said to contact him when she is 16 and done growing to have it fixed. Basically her septum was deviated, but way off, her entire nose was crooked.

She is now 17, we went back to the same ENT and he referred to us to a plastic surgeon that specializes in cleft surgeries because hers was so difficult. The surgeon agreed it should be fixed and told me his office would submit the paperwork to the insurance and not to worry because it was a birth defect and he saw no reason it wouldn't be covered. 2 or 3 weeks later his office calls, we're all set, we set the surgery.

4 weeks post op I get a bill from our insurance for $22k - the denial deemed it was not medically necessary. I called the insurance right away and said the prior authorization had been submitted, we weren't told this would cost us anything out of pocket!! She said the prior authorization was submitted for billing codes 30460 and 30462 and that their response to that was no prior authorization was necessary. Post op it was billed under a completely different code and that was denied. She put me through to an insurance advocate who will appeal the decision on our behalf. I'll hear back in 10-14 days. This bill does NOT include the doctor's bill or even anesthesia, I will be looking at close to $40k and most definitely bankruptcy if this denial holds.

Have you spoken to the doctor's office? Maybe they mistakenly put in the wrong codes post op? I think that would be the next thing to check.

this must be horribly stressful for you---I am sorry. I hope you are able to get it resolved quickly

 

[Grmnshplvr]

Have you spoken to the doctor's office? Maybe they mistakenly put in the wrong codes post op? I think that would be the next thing to check.

this must be horribly stressful for you---I am sorry. I hope you are able to get it resolved quickly

I left two voice mails since yesterday, I'm hoping they call me back ASAP. My fear is that they submitted the prior authorization codes incorrectly and the post op code correctly, which would mean while it was their mistake it would be my responsibility to pay.

 

[cvjw]

Hopefully your doctor can help get things straightened out since they submitted the incorrect code. If the worst were to happen, you can always work with the hospital directly to reduce the bill. That is the retail price, insurance companies and cash payers often pay much, much less.

As an example, I had 3 sessions of physical therapy after a car accident. The retail price was $1500. My health insurance wouldn’t pay since auto insurance was involved. The reduced price for the therapy thru insurance was about $500. The hospital wanted me to pay the whole $1500.

After talking to several people and explaining what was going on, I got a bill for $300 from the hospital - the cash price for the therapy. I paid it and the file was closed.

 

[TipsyTraveler]

I’ve had it happen a few times where I made reasonable advance effort to make sure I’d be covered just to then have them bill me after the fact with some excuse for why it’s not actually covered. I’ve always responded along the lines of “I did my part and was told I was covered. I won’t be paying this.” One time an insurance advocate got involved on my behalf and had the bill dropped, a couple of times the insurance company dealt with it themselves and resolved it in my favor after a few weeks, and more than once I got an immediate response of “Whoops, we didn’t mean to send you a bill, let’s just forget about it, mkay?” At this point, I’m fairly certain they send bills just in case anyone is willing to pay them, because my experience has been that the insurance company is quick to drop it as soon as you offer the least bit of resistance.

 

[MaryLovesPoohBear]

I left two voice mails since yesterday, I'm hoping they call me back ASAP. My fear is that they submitted the prior authorization codes incorrectly and the post op code correctly, which would mean while it was their mistake it would be my responsibility to pay.

Both of those codes are for nasal repair due to a cleft lip or palate.

I would definitely check what they submitted and what they were suppose to submit.

 

[StephMK]

Health insurance bills are the most difficult and stressful items to handle. It seems like co pays and deductibles are never applied in any logical way that I can understand. Try not to panic and let them refile. Since it is a birth defect and the dr said necessary, hope it was just a clerical error.

 

[DisneyHardin]

Don't stress out. Most likely there is just more paperwork to be submitted.

I had this sore swollen place on my leg and went to urgent care - the Dr. there thought it could be a blood clot and told me to go to the ER. At the ER they found that it was a clot, but in a varicose vein, so not dangerous and sent me home with instructions to follow up with a vein doctor. The visit got coded at the ER as "leg pain" and was denied by my insurance as not an emergency.

Luckily, the Urgent Care doctor had written in his notes for me to go to the ER and not just told me orally, so I was able to submit a copy of my Urgent Care checkout form and get it approved. It was stressful though while it was getting taken care of knowing I had this huge ER bill looming in my name out there.

 

[rwdavis2]

Call the doctor ASAP

 

[lifesavacation]

My sister had to file for medical bankruptcy. Her son got cancer and even with insurance she couldn't pay the mountain of bills that accumulated over months of treatment. So even if the worst happens and you can't get the bill resolved, there is NO shame in not being able to pay a huge medical debt. It's a broken system.

 

[superme80]

My sister had to file for medical bankruptcy. Her son got cancer and even with insurance she couldn't pay the mountain of bills that accumulated over months of treatment. So even if the worst happens and you can't get the bill resolved, there is NO shame in not being able to pay a huge medical debt. It's a broken system.

I'm not liking it because of what happened, but that it is a real option. So sorry your sister had to do that. To be dealing with her son's health AND the bills. I cant imagine.

 

[Pea-n-Me]

This reminds me of something that happened to us, too. It went something like this.

DD got a referral to a particular doctor. All set, made the appt with that doctor and she was waiting to see her, when DD had to change her appointment to a different time.

Doctors office said Dr. X was not available at the time DD could come in, but that Dr. Y was. So DD took the appt with Dr. Y.

When the bill came in, we found out that the visit wasn’t covered. After a lot of phone calls, we figured out it was because there was no referral for Dr. Y, even though Dr. Y and Dr. X were in the same practice.

Maybe it is something simple like that, and happened because you went to a different doctor. Hopefully.

 

[mnrose]

When my DD was hospitalized for three weeks, the insurance company denied the claim. They also denied the appeal. I kept at it, and appealed a second time (there were two layers of appeal in our insurance plan). Mind you that I called the insurance company from the ER waiting room (before she was admitted), and was told that her admission (if she was) would be covered for up to 3 days, at which point, we would need reauthorization. Thereafter, for the next 3 weeks, I called and spoke to insurance every 3-4 days for reauthorization. I kept careful records of every call. Time. Who I spoke with. What they said. Any codes, etc. Everything went into a notebook I kept. It was very, very annoying since my DD was very seriously ill and the LAST thing I wanted to do was handle insurance issues. After my second appeal, AND after getting my husband's HR department involved (they were appalled that the claim was denied!), I finally got a case manager assigned by the insurance company, and voila' it was paid. The hospital accepted less than 25% as full payment of the claim. I paid a few hundred OOP on top of that. I was so annoyed and angry. I also thought about how hard the entire process was for ME (an educated and trained lawyer) and how much harder it would be for your average lay person. It's so unfair.

What I learned: keep careful notes. DON'T quit! Make sure you read very carefully the specific requirements of your appeal...if you make a technical mistake, that is reason alone to deny the appeal. If your insurance is through an employer, contact them. My experience taught me that for "big claims" (i.e., something other than run of the mill doctor's visits), the knee jerk response of insurance is to say NO. Why wouldn't they? A certain percentage of people will give up and just assume the company is right, and there is NO meaningful penalty for them saying "no" so long as their denial is colorable. Doesn't cost them one penny more if they pay the first time or pay several months later after your appeal is granted.

 

[Pea-n-Me]

I should've added that our bill was eventually covered, we just had to get a referral number for Dr. Y.

 

[Pamlur]

Somebody wrote a book about insurance companies automatically saying no. I thought it was John Grisham, but I can't find it on Amazon; a young man was dying from leukemia and his insurance company kept denying his claim until he died. His mother sued them, a young lawyer took the case and won it because a clerk with the insurance company finally testified.

 

[HandOsmom]

Somebody wrote a book about insurance companies automatically saying no. I thought it was John Grisham, but I can't find it on Amazon; a young man was dying from leukemia and his insurance company kept denying his claim until he died. His mother sued them, a young lawyer took the case and won it because a clerk with the insurance company finally testified.

Yep - The Rainmaker

 

[Minnie17]

My hobbies include planning Disney vacations and fighting with health insurance companies. Multiple times I have received prior authorization for the 20+ surgeries my 13 year old has had performed. Then 3 months later the insurance company denies they provided prior authorization. I’m looking at you Anthem! Then I submit the grievance or whatever and it’s overturned eventually. However it’s a pain in the a$$ and we shouldn’t have to deal with it! Health insurance has ruined my credit but my child’s health is worth it! So my advice is keep fighting but don’t let it get you down.

 

[keaster]

I posted on a previous thread like this. As a Canadian I'm so sad that so many Americans have to go through this battle.

 

[CGB]

My experience taught me that for "big claims" (i.e., something other than run of the mill doctor's visits), the knee jerk response of insurance is to say NO. Why wouldn't they? A certain percentage of people will give up and just assume the company is right . . .

Nowhere near the same cost, but I had coverage for two dental crowns rejected by my insurance once. I fired back an appeal and won it. Years later, I was explaining what happened to a new (but older) dentist. He said he knew of some companies that would initially reject most claims because some people wouldn't appeal and just automatically pay OOP themselves. That taught me a thing or two about dealing with insurance companies!

 

[Skippy918]

When my dd was born, she got sick and ended up in the nicu. I got a bill for 75k. The letter said it wasn’t necessary. I appealed it right away and insurance covered it. Apparently, the hospital didn’t give them the right codes, but once they did that it was taken care of.