Medical Insurance/Hospital billing question

[chiefmickeymouse]

I'm hoping there are some medical insurance experts on here who can give me some advice. The scenario is:

My son was diagnosed with a genetic disorder a couple of months ago. The geneticist suggested a test for the gene. We did the test on May 15. The insurance company turned down the charge (even though it states in their handbook that the test is cover - company is Tricare, Humana). I receive a bill from the hospital for over $3000.

I call the insurance company. A very nice young man tells me that even though it states in the manual that it is covered, Humana routinely turns it down until proof of medical benefit is submitted. He also says that I'm not responsible for paying it if it is turned down (not sure why).

Today, the hospital's billing department calls me. The bill isn't even due for another week. I tell the young lady what the insurance company said. She said if the balance isn't paid during the next five statements, it will be turned over to a collections agency, no matter what the insurance company says.

That's my story. Anyone know what I should do? Do I wait? All advice is appreciated!

 

[Gracie09]

First write down the name, dye and what was said for every conversation. Second for an eob and what they need from the doctor to get it approved. Sometimes it just a more detailed letter.

 

[melwill530]

Speak to the billing manager or supervisor at the hospital and explain what the insurance company told you. Have them resubmit the bill explain to the supervisor that you are working with the insurance company to get the bill paid. They will usually note on your account a of this at the hospital.

 

[chiefmickeymouse]

Speak to the billing manager or supervisor at the hospital and explain what the insurance company told you. Have them resubmit the bill explain to the supervisor that you are working with the insurance company to get the bill paid. They will usually note on your account a of this at the hospital.

I did this and the billing person at the hospital said they were noting it on the account. It seems overly aggressive on the hospital's part to already be calling when the bill isn't even due yet.

 

[clutter]

I did this and the billing person at the hospital said they were noting it on the account. It seems overly aggressive on the hospital's part to already be calling when the bill isn't even due yet.

Perhaps they run into this a lot, and so they call ahead of the due date so that the patient can get the process started with the insurance company.

 

[DOREEN1779]

Yikes. I would think five statements is 5 months, so you have a bit of time before they will do anything. What the insurance company says sounds true. I would call the insurance company in a week and make sure they have received all the medical information needed. If they have not call the provider billing department ASAP. That $3000.00 is not a realistic number, that would be what you pay if you do not have insurance. The insurance company has contracts to what they pay and if you are covered, they will pay that amount. I would not stress about it but I would keep my eye on it. Just curious, did the procedure require pre-authorization?

P.S. If the hospital failed to get pre-authorization for a procedure that they are under contract for with the participating insurance carrier, they are responsible. It is not your job to submit the medical information, that is their job.

 

[OrangeCountyCommuter]

Call the hospital back. Ask for the Business Office Manager


Ask him/her why (a) they did not do any per verification on IF this would be covered. (B) why, if the problem is that the hospital failed to provide medical necessity proof ( which I'd what I think you are trying to say in the OP) it is YOUR fault and (c) why they are overly aggressive in collections (I read the law on collection harassment to the guy at my hospital when they called me at work 7 days after they mailed a bill)

 

[redmomof4]

I did this and the billing person at the hospital said they were noting it on the account. It seems overly aggressive on the hospital's part to already be calling when the bill isn't even due yet.

I would think they were being proactive because they received a denial from the ins co. It makes sense for the billing dept to start to recoup some of the charge (don't get me started on the outrageous fee!!). Contact the physician who ordered it and get them working for u to get it covered, also find out specifically what the ins co requires to get it covered!

Good luck!

 

[Stan's MaggieMouse]

It is the prescribing doctor's responsibility to get authorization for the test. The hospital as an entity is not allowed to request an authorization.

 

[HLAuburn]

I would call the insurance company as many times as it takes to get someone who is willing to do something about it. I'm sure they would like NOT to pay it, but as long as you jump through their hoops, they usually end up paying it if it's actually covered. I would ask them exactly what you or the ordering doctor/hospital need to submit in order to get it paid.

I would also go higher up at the billing office at the hospital and explain exactly what's going on. As long as you are communicating with them and keep them updated, they should cut you some slack and not be so jerky about it.

Good luck...I know it's a nightmare. I also received a $4200 bill from a lab for covered tests. In the end (and after about 6 months), it just had to be recoded a certain way, but they paid it. If I hadn't have pressed the issue and called 100 times, I'm sure they would have loved for me to pay it instead, so you just have to be pushy!

 

[Aidan's Mommy]

It is the prescribing doctor's responsibility to get authorization for the test. The hospital as an entity is not allowed to request an authorization.

Not true. Ultimately, it is the patient's responsibility to make sure that the services they are getting are covered. The insurance company should be submitting to the hospital a request for more medical documentation supporting the need for the test to have been done. Usually, once they receive that..it is covered.

What the insurance company told you as far as if the insurance denies the claim, the the hospital writes off the claim is horribly incorrect. If the insurance denies a claim, the hospital will come to you for payment. That's why it's always important to make sure you have coverage or a referral for services if needed.

 

[tvguy]

I had a run around with a hospital over a $10,000 bill. Insurance said it was covered, but said the hospital never submitted a claim.
Hospital says they mailed a claim.
I went back and forth with the hospital for three months, and then they say one more month, and it goes to collections
Then, I get a big envelope from the dead letter office. Inside is the claim form. The hospital envelope had no return address, and the hospital did not put postage on the envelope .
So I call the lady at the hospital, she really had been very nice the entire 3 months, but firm that I had to pay the bill. I told her I would invest the cost of a stamp to move the process along......she just started laughing apologized, and even made a point of calling me 10 days later when the claim was paid and told me "guess we could have settled this 3 and a half months ago if we had just put a stamp on the envelope.

 

[nyrebecca]

I would suggest calling the insurance company again and explain that you have been told it was declined but you were not responsible however are being billed. I work for a health insurance company and make calls to billing offices all the time to have things like this straightened out. Perhaps your insurance has a department that can handle that for you.

 

[TrulyMadlyDisney]

Tricare/Humana is notorious for denying claims. They always tell the patient that it is the hosp/doctors fault that the bill is denying. Sounds like they require documentation to prove medical necessity. I would call the hosp and make sure they received the remit from Tricare with a request for it. If not call Tricare back and ask them what they need. You cannot let it go. Unfortunately if you dont stay on it they wont pay. If this was a blood test, in the future i would go to a lab, not a hospital to have it done. Alot of insurances do not cover labs done at the hosp. Too expensive and if done in the hosp, the charge will fall under your hospital coverage with the higher deductible.

 

[chiefmickeymouse]

I had a run around with a hospital over a $10,000 bill. Insurance said it was covered, but said the hospital never submitted a claim.
Hospital says they mailed a claim.
I went back and forth with the hospital for three months, and then they say one more month, and it goes to collections
Then, I get a big envelope from the dead letter office. Inside is the claim form. The hospital envelope had no return address, and the hospital did not put postage on the envelope .
So I call the lady at the hospital, she really had been very nice the entire 3 months, but firm that I had to pay the bill. I told her I would invest the cost of a stamp to move the process along......she just started laughing apologized, and even made a point of calling me 10 days later when the claim was paid and told me "guess we could have settled this 3 and a half months ago if we had just put a stamp on the envelope.

Wow, that is crazy. The whole medical insurance/billing system is a nightmare.

 

[chiefmickeymouse]

Tricare/Humana is notorious for denying claims. They always tell the patient that it is the hosp/doctors fault that the bill is denying. Sounds like they require documentation to prove medical necessity. I would call the hosp and make sure they received the remit from Tricare with a request for it. If not call Tricare back and ask them what they need. You cannot let it go. Unfortunately if you dont stay on it they wont pay. If this was a blood test, in the future i would go to a lab, not a hospital to have it done. Alot of insurances do not cover labs done at the hosp. Too expensive and if done in the hosp, the charge will fall under your hospital coverage with the higher deductible.

The test was done at the lab in the building where the doctor works, which is part of a huge complex that is part of the hospital's "system". I had no idea it would be different from any other lab.

Part of the problem we are having is that we are fresh out of the military medical system. We only saw doctors at military treatment facilities unless referred by them to a specialist. We never even saw a bill. Now we are knee deep in specialists (he has 6, not including his pediatrician) because of my son's condition and I'm trying to wade through the process.

 

[angwill]

Call the hospital back. Ask for the Business Office Manager


Ask him/her why (a) they did not do any per verification on IF this would be covered. (B) why, if the problem is that the hospital failed to provide medical necessity proof ( which I'd what I think you are trying to say in the OP) it is YOUR fault and (c) why they are overly aggressive in collections (I read the law on collection harassment to the guy at my hospital when they called me at work 7 days after they mailed a bill)

I hate to tell you but collection harassment is only a rule for collection agencies and not first party collections if the company is collecting for themselves.

 

[kim929]

I hope your son is doing well.

The ins company might of said you wouldn't be responsible because the Dr or hospital didn't send in the right information in the time frame allowed.
I received a bill from a Dr for an outstanding bill. I called the insurance company and they told me they didn't pay it because the Dr office didn't submit the claim in the amount of time given so it's the Dr office fault and I'm not responsible for it.

Good luck, it's not fun having to deal with insurance company's and billing offices.

 

[lovemygoofy]

The test was done at the lab in the building where the doctor works, which is part of a huge complex that is part of the hospital's "system". I had no idea it would be different from any other lab.

Part of the problem we are having is that we are fresh out of the military medical system. We only saw doctors at military treatment facilities unless referred by them to a specialist. We never even saw a bill. Now we are knee deep in specialists (he has 6, not including his pediatrician) because of my son's condition and I'm trying to wade through the process.

Are you near a MTF now or any branch of the military installation? If you are near a MTF or a installation, go talk to the tri-care office AND go talk to the EFMP personnel. The EFMP can help you wade through the paperwork to a point.

If you call back to Tricare, skip the first level of the customer service and go to referral management. I know it's not a referral problem but they will be able to help figure out the procedure. Ask if you need to fill out any other forms from Tricare to get the testing covered.

I had a major surgery last year and all paperwork was filled and Tricare approved before I had my ankle surgery. The surgery was out on the economy and the bills started to roll in for 10k here another 8k there and all said and done it was close to 27k. I received a denied letter from Tricare because one form was not filled out which they never mailed. I called freaking out about the denial because I was getting all these bills in the mail. Tricare customer service was like don't worry we will take care of it. Anyways, they did ultimately pay out for everything but it took the surgery center, doctor office and other offices to billing repeatedly.

Now that you are going to be seeing civilian doctors, make sure you understand all the rules from Tricare and it's more confusing because you are using Tricare 4 Life I'm guessing. EVERYTHING needs to be pre-approved and remember if you are near a MTF you can take the prescription for the test to the MTF to be done.

 

[LilyWDW]

Another thing I learned from my mom's long illness is to NEVER pay the bill you get from the hospital (or other provider) until you verify it against your insurance. I had more then one bill come in for the FULL amount. When I checked it against the insurance I would find that the amount should be a lot less (as in $35 instead of the $500 or so). They were billing the nondiscounted, noninsurance amounts. If I had not known about this I would have paid WAY more then I was actually responsible for.

Also, get an itemized bill so you can check everything!