Insurance claims experts/experience?

[Straycat]

I'm looking for advice from anyone who works in the insurance field or has had experience dealing with insurance claims.

For my recent pregnancy, my insurance carrier was/is United Health Care (UHC) through my work. For maternity services, it was my understanding that I would pay a copay at the first visit and nothing after that until the hospital stay. For the delivery, I would pay $50 a day, up to 5 days. (I do have a $100 bill for my 2 nights which is not a problem).

The morning I had my son, I went to the hospital per my doctors request to have a few tests run due to high blood pressure 2 days previous. At that time, he determined that I had developed severe pre-eclampsia and would need to have csection right away. He told me to call my DH and that he would be delivering my baby in about two hours. (the hospital needed this much time to get the correct staff available).

My OB is in network and the hospital is an in-network hospital.

Yesterday, I received an 'explanation of benefits' letter letting me know that I would be required to pay $1000.75 for the physician's assistant because he was out of network. We called UHC, they said the same thing, we chose an out of network physician's assistant and we have to pay.

We did not realize that while I was drugged up and tied down in the operating room that I should be polling anyone in there asking them 'hey are you in network'... We 'assumed' that everything was taken care of. To this date, I don't think I ever saw this assistant, I don't even know his name yet, certainly didn't 'choose' him. The hospital did have my insurance information well before the date of my csection.

So, DH says we have to appeal the decision. Any advice on what I need to include with the appeal letter to get this decision reversed?

 

[bettyann29]

I am a health insurance claim examiner and pay claims.. I dont make the decisions on appeals but I can tell you when an insurance claim is being paid they pay exactly as your policy reads.. There are so many I want to pay but unfortunately thats not my call.. If this dr is oon and there are extenuating circumstances as in your case than you will have to appeal it to get it reconsidered.. They are probably looking at this as you scheduled it and it wasnt an emergency..but thats not the case.. If this was a normal delivery than you wouldnt have needed an assistant surgeon.. the same goes for the anesthesiologist in the event of something that isnt planned.. You generally go with who is on duty and have no control over this.. Thats why insurance companies have something that is called RAPS- Radiology, Anesthesiology, Pathology... This means if te hospital is participating and you get a bill from one of these providers than you allow at the innetwork benefits.. This dr is not any of these types of specialists and thats probably why they paid him as out of network since he is.. if you go to a participating hospital you have no control over who they employ and it sounds like this dr happened to be at the hospt that day and you got him..

There is no other way other than appealing.. Be direct.. Explain the events as they happened and reinterate that you went to a participating hospital and have no idea who is oncall at their facility.. also explain in the letter that you already called the insurance company and was told they couldnt help you.. Put names if you have them of who you talked to.. You did your part as you chose an innet dr and hospt.. I dont know what state you are in as Im now posting and dont see that info.. but I would include in your letter that you are also sending a letter to the (State you live in) Dept of Insurance regarding this matter.. I dont normally tell anyone to do that but your appeal letter WILL be taken seriously with that remark on there.. and follow thru.. look up your state dept of insurance and send them a copy of the letter.. They do investigate all letters.. they also contact the insurance company regarding the letter and the insurance company has to give to them what they are doing to resolve the matter.. I cant imagine that you wont get results..

Alot of people dont know about the dept of insurance.. You have a legitimate complaint and you tried to resolve it with a phone call.. Keep copies of everything you send to everyone.. If you talk to someone write down their name.. This helps when you can give exact info..

Hope this helps..

 

[mla2177]

The same thing happened to me with the birth of my son. I developed severe Preeclampsia and was airlifted from the hospital to another that had a NICU (my son was born at 32 weeks). Anyway, a couple of weeks later I got a bill in the mail for the helicopter ride of $10,000 !!!! They said the carrier was out of network. My husband made several phone calls and wrote many letters to the insurance co and the original hospital, and they wrote it off. Like you, I didn't choose the carrier, they did! They knew which insurance I had!!!!

I say fight it.............they can do something about it!!!!!!

Good luck, congrats on the new baby. I hope all is well!

 

[Straycat]

BettyAnn - Thank you Thank you Thank you. I will definately take your advice about the Dept of Insurance. Talking with my DH this morning, he said that UHC does not have it listed as an emergency csection even though I delivered about a month early and the baby spent 6 days in NICU. I will be sure to get my OB to put something in writing documenting the emergency nature of this delivery.

Thank you again.

mla - Thanks for your feedback, its good to know that these can be appealed and won. My DH seems to think they all get denied.

 

[buzzlady]

Not the same as a pregnancy but DH went to ER for shortness of breath and dizziness. He had had a heart attack in the past and we weren't taking any chances (turned out to be a blood clot).

A few weeks/month later we got a bill for the ER Dr and also from a Radiologist that read his xrays. Neither was a participant. I called the insurance company and told them that we went to a participating hospital and I had no idea which drs. in the hospital participate. Its and EMERGENCY and I didn't think to stop and ask every person that touched DH if they participate.

The did pay the claims.

 

[my3kids]

Something similar happened to me. Tissue samples were sent by the surgeon to a pathologist who wasn't "in the network." I got an initial denail of the charge. I wrote them saying pretty much the same thing....once I was asleep I really didn't know where the samples went and it wasn't my option to select the specialiat my surgeon worked with. They went ahead and paid it in full.

 

[bettyann29]

BettyAnn - Thank you Thank you Thank you. I will definately take your advice about the Dept of Insurance. Talking with my DH this morning, he said that UHC does not have it listed as an emergency csection even though I delivered about a month early and the baby spent 6 days in NICU. I will be sure to get my OB to put something in writing documenting the emergency nature of this delivery.

Thank you again.

mla - Thanks for your feedback, its good to know that these can be appealed and won. My DH seems to think they all get denied.

You're welcome.. I can tell you from first hand experience that when Dept of Insurance gets involved the insurance companies take notice.. I dont normally tell people about them because you should try to handle it on your own level first but if thats not working and its just not right the way they are doing it than it needs to be taken to another level.. From the insurance perspective I think many people use DOI too much for things they shouldnt.. but hey.. it gets them what they want.. After so many complaints DOI will come in and investigate an insurance company so the insurance companies do stand and take notice when they see DOI has been contacted..

Definitely get the dr to write a letter and include that..