skimomma Posted May 20 Share Posted May 20 (edited) Thanks everyone! Deleted for privacy. Edited May 21 by skimomma 3 Quote Link to comment Share on other sites More sharing options...
prairiewindmomma Posted May 20 Share Posted May 20 Contact the insurance commissioner for your state, and consider hiring an attorney. 8 2 Quote Link to comment Share on other sites More sharing options...
KSera Posted May 20 Share Posted May 20 A couple ideas for you: 1. You could file a complaint with your state insurance commissioner. Sometimes thay gets things going 2. you could see what kind of relief plans the hospital offers. They often have programs to reduce out-of-pocket costs for those that need it. Unfortunately, like what you’ve experienced with insurance already, it’s an awful lot of legwork to file at all. 3. in the meantime, often you can pay just $50 or so a month to keep the bill current and have it not being sent to collections or anything sorry you’re going through that. We have dealt with similar recently, and it’s insane how much time, effort and energy it takes to resolve it. There’s almost no way that anyone with disabilities and/or low resources would be able to do so, which is just not fair. 3 Quote Link to comment Share on other sites More sharing options...
Katy Posted May 20 Share Posted May 20 Do file a complaint with the insurance commissioner immediately. In most states you can do this online. They pre-authorized a medically necessary procedure that they are legally obligated to pay. Do contact area attorneys and ask by phone for their advice. Do make payment arrangements for the hospital in the meantime. This could be very minimal. Even $20/month to keep current. 5 Quote Link to comment Share on other sites More sharing options...
skimomma Posted May 20 Author Share Posted May 20 20 minutes ago, prairiewindmomma said: Contact the insurance commissioner for your state, and consider hiring an attorney. I have the link for the commissioner and that is my next plan. I have to assume I will pay more than the $4500 if I have to hire a lawyer? Quote Link to comment Share on other sites More sharing options...
skimomma Posted May 20 Author Share Posted May 20 I have been back and forth with the provider and the lowest they will go for monthly payment is $1125/month, which I cannot pay. I should be concentrating on recovering, not this! 4 Quote Link to comment Share on other sites More sharing options...
skimomma Posted May 20 Author Share Posted May 20 I'm hoping someone has worked through this specific issue. A "coding error" and how to get that specifically resolved when the provider claims it is correct. Quote Link to comment Share on other sites More sharing options...
Lecka Posted May 20 Share Posted May 20 (edited) I have also heard to contact the insurance commission. I have heard of things being resolved within two weeks this way. Edit: I’m sure that’s unusually good, but I have heard of it happening more than once! I have heard of it being much better than people expected. Edited May 20 by Lecka Quote Link to comment Share on other sites More sharing options...
gardenmom5 Posted May 20 Share Posted May 20 I messaged you Quote Link to comment Share on other sites More sharing options...
prairiewindmomma Posted May 20 Share Posted May 20 28 minutes ago, skimomma said: I have the link for the commissioner and that is my next plan. I have to assume I will pay more than the $4500 if I have to hire a lawyer? It’s my hope that this could be a quick thing—advisory letter or such. The insurance company authorized certain codes. Billing clearly did not match those codes. You should be able to see what codes were used inside of your insurance company portal. If the hospital used different billing codes, I would want to know why. I suspect this is a hospital error, and a note from an attorney may cause higher level review. 1 Quote Link to comment Share on other sites More sharing options...
gardenmom5 Posted May 20 Share Posted May 20 16 minutes ago, Lecka said: I have also heard to contact the insurance commission. I have heard of things being resolved within two weeks this way. Edit: I’m sure that’s unusually good, but I have heard of it happening more than once! I have heard of it being much better than people expected. yeah - if you want to put the fear of God into an insurance company . . . it will put some fire under their tails . . . Quote Link to comment Share on other sites More sharing options...
EKS Posted May 20 Share Posted May 20 It sounds like it might have been the provider's fault in that they provided the wrong codes in the pre-authorization process. Did I interpret that correctly? If that's the case, you may be able to get them to back down on their end. Also, if nothing else works, you may be able to get them to charge you the same price as they would have charged the insurance company. 1 Quote Link to comment Share on other sites More sharing options...
aaplank Posted May 20 Share Posted May 20 I'm sorry you are going through all this, especially with trying to recover. I have been in a similar situation with you could not get anywhere with either my provider or insurance. However, I have also had success with having the provider resubmit the claim with new codes. I would go to a higher up with your provider, explain your situation and ask them to resubmit the claim with the code you need to have the insurance accept it. 3 Quote Link to comment Share on other sites More sharing options...
Karen A Posted May 20 Share Posted May 20 I have nothing to add, but that I am sorry you are going through all this stress at a time that has been stressful itself due to the surgery. You have done all the right things, and I have just prayed that justice will be done and you will soon be relieved of this additional burden. Quote Link to comment Share on other sites More sharing options...
Laura Corin Posted May 21 Share Posted May 21 I don't have experience of this myself, so take this with a grain of salt. I seem to remember a case on the board where a routine colonoscopy discovered something that needed to be investigated separately. It was therefore coded as 'diagnostic' rather than 'screening/routine'. However, the insurance company had pre-approved the screening/routine procedure and therefore turned down the 'diagnostic' coding. Just something to investigate if it makes sense to you. 2 Quote Link to comment Share on other sites More sharing options...
TexasProud Posted May 21 Share Posted May 21 No suggestions, but this really stinks. Insurance coding is a joke. Quote Link to comment Share on other sites More sharing options...
Alice Posted May 21 Share Posted May 21 (edited) Have they told you what the codes are? That might be helpful in figuring out where the error was. It sounds like possibly the person who sent in the request for the pre-authorization used a different code than they used in the final coding of the procedure and maybe that is why they now won't pay. That's just a guess. It might have been an error and it might just be what is now often called "retrospective denial". For example....and using examples not related to you so as not to guess at your medical issues....if you had a chest X-ray done for a cough and the doctor saw something that made them worry about a tumor so got a CT preapproved with the code "lung mass unidentified" but then when they did it they saw it was actually an aneurysm of a vessel around the heart and so on the coding for the diagnosis was "aneurysm" they might say that a better procedure would have been an ultrasound first and therefore the CT was "Unnecessary". And to be clear, I think insurance and coding and billing is all incredibly stupid and annoying and I am 100% sure that insurance companies at this point are basically just figuring out how not to pay for stuff. So I'm not justifying that, just guessing that is what happened. As a provider, I have been in the situation many times where I've coded something and then been told I have to code it differently for insurance to pay. Sometimes, I can't without lying....like I have a parent that requested a blood test for a kid based on family history but insurance will not cover it unless I can code that the kid has symptoms that they don't have. (But I haven't ever had it happen where we got a pre-auth and then it was denied..that's insane, but also sadly becoming more and more common. There are efforts by the AMA and other organizations to have it be made illegal.) I've also had it happen where it's as simple as something being denied because I used a code that to me seems like the same thing as another code but insurance will cover one and not the other. Or something like they require a much more specific code that I've used. Usually I just call our office billing person and ask them what code I need to put to make it most likely to be covered in the appeal. And if it's not legitimate, I'll change the code. Have you talked to the billing people at the office where it was done? Or the manager? If you've only talked to the provider that might be the issue. As a provider, I have no idea half the time what insurance wants to see in order to get them to cover things, so we have billing/coding specialists who will do that. If one of those people at the hospital hasn't been involved since it was originally sent in, maybe they could look at it and see. Sorry, that's not more helpful. This sucks and I'm really sorry you have to go through this. Edited May 21 by Alice 1 Quote Link to comment Share on other sites More sharing options...
skimomma Posted May 21 Author Share Posted May 21 Thanks everyone! Those of you who suggested I press more into the coding were right! I worked on that late last night and sent a summary of everything to the provider asking them to review the codes and resubmit. I didn't think I'd get anywhere because they already "reviewed the codes" twice before. But I spelled it out in extreme detail that I wanted them to review the codes against the pre-auth, of which I attached a copy. Just now, I got a response that there is indeed a coding error and they will resubmit. Of course, this does not mean it is over but at least something is happening. I can see them pulling a retro-decline because as Alice describes, I believe an ultrasound would have been the most economic next step had the doctor been able to predict the future. I have a meeting scheduled for tomorrow with my employer's insurance liaison, which I will still attend, if for no other reason than to make sure it is all documented with my employer. Fingers crossed! 12 Quote Link to comment Share on other sites More sharing options...
Scarlett Posted May 21 Share Posted May 21 (edited) edited to add we were posting at the same time. Glad you are getting somewhere. When my Dh had his ablation the hospital failed to get a pre approval and it cost the hospital about denial,letter specifically said the hospital could not come after me. I know it is a lot of work and very stressful but I would dig into the very specific codes that were used for pre approval vs actual billing. My guess is this is the providers error but you will have to scream loud enough for someone to listen. I assume you have asked for all the supervisors that you can. Also contact insurance commissioner asap. Edited May 21 by Scarlett Quote Link to comment Share on other sites More sharing options...
Laura Corin Posted May 21 Share Posted May 21 1 hour ago, skimomma said: Thanks everyone! Those of you who suggested I press more into the coding were right! I worked on that late last night and sent a summary of everything to the provider asking them to review the codes and resubmit. I didn't think I'd get anywhere because they already "reviewed the codes" twice before. But I spelled it out in extreme detail that I wanted them to review the codes against the pre-auth, of which I attached a copy. Just now, I got a response that there is indeed a coding error and they will resubmit. Of course, this does not mean it is over but at least something is happening. I can see them pulling a retro-decline because as Alice describes, I believe an ultrasound would have been the most economic next step had the doctor been able to predict the future. I have a meeting scheduled for tomorrow with my employer's insurance liaison, which I will still attend, if for no other reason than to make sure it is all documented with my employer. Fingers crossed! Hooray! Quote Link to comment Share on other sites More sharing options...
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