Insurance denial and $22k bill

[Planogirl]

When I had my accident, the emergency surgeons turned out to be out of network. I couldn't exactly check into that since I was unconscious. The insurance refused to pay more than out of network coverage and the surgeons wanted the whole amount. I appealed endlessly but neither side would budge and most of the surgeons wanted complete amounts and refused to accept reasonable payments. I had no choice but to pay them nothing more because it was so much money and I had all kinds of other expenses.

I guess that my point is that you can only do what you can. If they get stubborn and dig in their heels get as much help as you can. I agree to not give up even though it didn't work for me because no matter what happens it's definitely clear that I tried.

 

[jalapeno_pretzel]

We've had a couple of hospital visits where the hospital is in network but pathology is out of network - as if we have a choice where blood work is done once we're in the hospital. Compounding it, is that the pathology sends 2 bills - one for the physical component (covering use of the lab equipment), and one for the personnel component (the technicians performing the work). Insurance initially denied all pathology as out of network. Then once we argued the hospital is in network and we have no choice, they accepted it, but only paid one of the two bills. When we would call them back, they would insist they had already paid the pathology bill. Then I contact the pathology office, where they explain the 2 separate bills to me, back to the insurance, where they still insist they paid it, back to the pathology office, where their insurance person gives me the secret terminology - "point out that this code has the dash 26 modifier." She says the insurance knows exactly what it is and they're just trying to get out of paying it. Once we mention the -26 modifier to the insurance company, magically they manage to figure it out and pay that bill. 2 months later, another hospital visit, we go through the EXACT same thing. The insurance companies are doing it on purpose to see what they can avoid paying.

 

[alizesmom]

It is my firm belief that you will receive a lot of denials and red tape because insurance companies hope you’ll just give up.

 

[Pea-n-Me]

We've had a couple of hospital visits where the hospital is in network but pathology is out of network - as if we have a choice where blood work is done once we're in the hospital. Compounding it, is that the pathology sends 2 bills - one for the physical component (covering use of the lab equipment), and one for the personnel component (the technicians performing the work). Insurance initially denied all pathology as out of network. Then once we argued the hospital is in network and we have no choice, they accepted it, but only paid one of the two bills. When we would call them back, they would insist they had already paid the pathology bill. Then I contact the pathology office, where they explain the 2 separate bills to me, back to the insurance, where they still insist they paid it, back to the pathology office, where their insurance person gives me the secret terminology - "point out that this code has the dash 26 modifier." She says the insurance knows exactly what it is and they're just trying to get out of paying it. Once we mention the -26 modifier to the insurance company, magically they manage to figure it out and pay that bill. 2 months later, another hospital visit, we go through the EXACT same thing. The insurance companies are doing it on purpose to see what they can avoid paying.

So frustrating! I went through something like that, too, after my DD's surgery. I called around up the ying yang, but no go, had to pay it. Then one day down the road I was talking to someone at our health insurance carrier about something else, when I brought that up. She asked me to hold on a minute, then came back and said it's all taken care of, i.e. she had somehow gotten rid of it, just like that! I was flabbergasted!

We are going through the same thing now with one of our kids' FAFSAs. (Though both kids have had it happen.) Things somehow get screwed up once you send them in, idk how. Once it was a name spelled incorrectly - though it was correct when sent out - and that caused a lot of problems. Right now they're saying my son has another degree - which he doesn't. I think it's some of the software that processes these things, along with codes or whatever. Trying to get them fixed practically takes an Act of God.

 

[smiths02]

I hope you got a hold of the doctor's office.

We had a very minor version happen to us. We went to a follow-up with the neurosurgeon and then got a letter that it was denied as not necessary. It was a follow-up with a neurosurgeon...you can't even get a follow-up appointment with the neurosurgeon that is not necessary! Called the doctor office and some number had been transposed somewhere (either on the original diagnosis or something). Anyhow, the doctor's office resubmitted and all was well.

 

[NHdisneylover]

So frustrating! I went through something like that, too, after my DD's surgery. I called around up the ying yang, but no go, had to pay it. Then one day down the road I was talking to someone at our health insurance carrier about something else, when I brought that up. She asked me to hold on a minute, then came back and said it's all taken care of, i.e. she had somehow gotten rid of it, just like that! I was flabbergasted!

We are going through the same thing now with one of our kids' FAFSAs. (Though both kids have had it happen.) Things somehow get screwed up once you send them in, idk how. Once it was a name spelled incorrectly - though it was correct when sent out - and that caused a lot of problems. Right now they're saying my son has another degree - which he doesn't. I think it's some of the software that processes these things, along with codes or whatever. Trying to get them fixed practically takes an Act of God.

Once the FAFSA system decide I was the student and my oldest was the parent! This was for Junior year, started working from the old form which had been right. No IDEA how the got that messed up---but it also took forever and a day to straighten out.

 

[BLAZEY]

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.

Same here. I may wait a bit for non-urgent care, but at least I don't have the stress and worry about claims being denied or large bills. $25 a week for parking at the hospital is nothing.

 

[LYSE]

I hope you get it sorted out, if not honestly I would probably deal with the credit ding for 7 years..why bankrupt your self when you can just ride it out?

 

[Mrs. Ciz]

So frustrating! I went through something like that, too, after my DD's surgery. I called around up the ying yang, but no go, had to pay it. Then one day down the road I was talking to someone at our health insurance carrier about something else, when I brought that up. She asked me to hold on a minute, then came back and said it's all taken care of, i.e. she had somehow gotten rid of it, just like that! I was flabbergasted!

We are going through the same thing now with one of our kids' FAFSAs. (Though both kids have had it happen.) Things somehow get screwed up once you send them in, idk how. Once it was a name spelled incorrectly - though it was correct when sent out - and that caused a lot of problems. Right now they're saying my son has another degree - which he doesn't. I think it's some of the software that processes these things, along with codes or whatever. Trying to get them fixed practically takes an Act of God.

Once the FAFSA system decide I was the student and my oldest was the parent! This was for Junior year, started working from the old form which had been right. No IDEA how the got that messed up---but it also took forever and a day to straighten out.

Oh Dear Lord - the FAFSA! DH made a HUGE mistake DS's sophomore year. DH and DS have the same name. One is a junior, the other a III. DH put all his info where DS's should be and DS's info where DH's should be. It made it look like DS was more that 50% financially responsible for a minor child - his sister. He was awarded Pell Grants that we knew nothing about until DS started getting refund checks from the school for all the money we'd paid thus far. I looked up his account, saw the Pell Grant, emailed the Financial Services office to ask if we should really have that money. I was pretty sure we didn't qualify for a Pell Grant. They kept saying the money was his and dropping the issue. It took several phone calls for them to actually investigate like I asked them too. Once they started looking, they found the problem right away. We had them put a hold on DS's account so no Pell money would get credited for the Spring semester, returned all the uncashed refund checks, and amended the FAFSA. I knew if we didn't give that Pell Grant money back, someone would come looking for it down the line. I didn't want any trouble with the federal government! It all got straightened out in the end, and DH was super careful filling out future FAFSA and CSS profiles after that!!!

 

[DopeyDame]

Two things that might be useful:
1. A very nice insurance guy on the phone once told me that I should appeal something at least 3 times. He said the first appeal they literally just check for a mistake. Is your name wrong, did someone click no instead of yes, did someone transpose numbers when they were entering something, etc. (Hopefully the code issue falls into this category!!!) The second time, a human actually looks at the content of your appeal. Some get overturned here if it's reasonable. The third appeal is when the medical board at the insurance company actually gets involved and does research if necessary. Obviously that's just the word of this one guy and I'm sure each company handles things differently, but it's something to keep in mind.

2. Most states have a consumer protection offices or consumer protection divisions within the state attorney generals office. These people can help you file a complaint for free. For example, here's Maryland's: http://insurance.maryland.gov/Consumer/Pages/FileAComplaint.aspx
I once had a disagreement with my insurance agency. Once I requested the information from the consumer protection branch, everything was magically cleared up right away.

Good luck! So sorry you're dealing with this!

 

[NHdisneylover]

Oh Dear Lord - the FAFSA! DH made a HUGE mistake DS's sophomore year. DH and DS have the same name. One is a junior, the other a III. DH put all his info where DS's should be and DS's info where DH's should be. It made it look like DS was more that 50% financially responsible for a minor child - his sister. He was awarded Pell Grants that we knew nothing about until DS started getting refund checks from the school for all the money we'd paid thus far. I looked up his account, saw the Pell Grant, emailed the Financial Services office to ask if we should really have that money. I was pretty sure we didn't qualify for a Pell Grant. They kept saying the money was his and dropping the issue. It took several phone calls for them to actually investigate like I asked them too. Once they started looking, they found the problem right away. We had them put a hold on DS's account so no Pell money would get credited for the Spring semester, returned all the uncashed refund checks, and amended the FAFSA. I knew if we didn't give that Pell Grant money back, someone would come looking for it down the line. I didn't want any trouble with the federal government! It all got straightened out in the end, and DH was super careful filling out future FAFSA and CSS profiles after that!!!

Oh what a mess!
we only have one FAFSA left to file. I will be so happy to be done with that forever

 

[StephMK]

When DD22 had a medical emergency, she spent 2 days in the hospital. It took months for all the bills to filter in. I did not pay them until I started to get 2nd or 3rd notices. The amounts changed as things shook out and different charges were on statements.

Also, insurance charged her ambulance trip as out of network from one covered ER to another.$1200 difference It was a necessary trip because the 1st ER was not equipped for what she needed. I appealed because why would we know to ask about an out of network transport when both facilities were in network and we were out of state. Not to mention it was a time critical situation.

The appeal was denied for a bs reason. A year and half later, the total amount was mailed to us by the insurance company. No explanation. When DH called, they just said it was due to an audit.

It made a stressful situation continue because it was such a billing nightmare. Also Anthem as another pp mentioned above.

OP-did you get anything answered today?

 

[luvbwv]

A number of years ago I had jaw surgery, I received a pre authorization letter from my insurance company. After the surgery the claim was denied. There was some wording on the pre authorization to the effect that it wasn't guaranteed to be covered, which was standard wording at that time. The insurance company decided it was cosmetic and would not cover it. I went through all the appeals and lost. I had written testimony from dentists and oral surgeons saying it was not cosmetic, but it still did not get covered.
I hope you have different results and you get everything paid for. In my case, the oral surgeons office was very understanding and discounted it as much as they could but I still owed over $20,000.
Good luck!!!

 

[Geoff_M]

First of all, make sure your insurance company really is saying that you're on the hook for the bill. You may be misinterpreting the EoB sent to you. Last year we got an EoB for some genetic testing my wife's doctor had performed and she was told insurance would cover it during the appointment. A couple months later we got an EoB in the mail that the $1.5k (IIRC) was denied because they required prior authorization and it was not obtained. They said I could appeal it, and I did. That was denied too. But when I called the insurance company back afterwards and mention that I didn't think I should have to pay because the doctor's office didn't do things right, the rep told me that I didn't have to pay anything. She said that the terms of the network agreement with the provider barred them for seeking money from us in cases when the provider didn't follow procedure when providing service or filing a claim. The provider had to eat the cost of my wife's test because they didn't get the clearance beforehand. But the EoB simply said they were paying $0 and we just assumed that meant we'd have to pay instead. In the end it cost us nothing.

 

[Pea-n-Me]

First of all, make sure your insurance company really is saying that you're on the hook for the bill. You may be misinterpreting the EoB sent to you. Last year we got an EoB for some genetic testing my wife's doctor had performed and she was told insurance would cover it during the appointment. A couple months later we got an EoB in the mail that the $1.5k (IIRC) was denied because they required prior authorization and it was not obtained. They said I could appeal it, and I did. That was denied too. But when I called the insurance company back afterwards and mention that I didn't think I should have to pay because the doctor's office didn't do things right, the rep told me that I didn't have to pay anything. She said that the terms of the network agreement with the provider barred them for seeking money from us in cases when the provider didn't follow procedure when providing service or filing a claim. The provider had to eat the cost of my wife's test because they didn't get the clearance beforehand. But the EoB simply said they were paying $0 and we just assumed that meant we'd have to pay instead. In the end it cost us nothing.

I've had genetic testing done in depth, and every now and then they discover a new DNA strand so they test me for that, too, when it comes up. They always warn me that insurance may not pay for it, but if that happened, they'd give me several years to pay for it. I haven't had it denied yet. But it's a strange approach to the whole thing.

 

[wgeo]

Sad how many similar stories everyone has. My dad is currently fighting a 21000 bill that he got for an helicopter ambulance ride and of course it says full amount due in 15 days.

When my son was born he ended up in the NICU. First the insurance denied because I didn't call the day he was born and officially add him to the policy. OK, I guess that was my fault so we got that fixed. Then, while he was in an in-network hospital he needed a CAT scan and apparently they are out of network, so that got denied. Nearest in-network cat scan was 45 minutes away. It took 3 appeals before they covered it, I was like so your theory is that we should have used an ambulance to transport my 4 day old child 45 minutes to have a cat scan and then ambulance him 45 minutes back to the original hopsital, just to stay in network? It was stressful, but they did finally cover it.