Typical budget buster - medical ins. won't pay claims

[apirateslifeforme]

The background: On the advice of my gynecologist, DH and I began seeing our reproductive endocrinologist on February 28, 2012. She is located in Connecticut. We live in Massachusetts, but DH worked in CT and had CT insurance at the time. This doctor discovered that I had extreme problems that she felt she couldn't address, so she sent me to another RE who had more expertise. After several medications and 2 surgeries, he returned me to the first RE for further treatment. Our insurance paid for everything.

In November DH's company was bought out and he was transferred to the main office in MA. On January 1st, our insurance changed to MA as well (so now, we have a CT doctor and MA insurance). Since we were still in treatment, we continued to see this doctor, as my problems are so severe that we really don't have time to start over with a new doctor. Before we began the next phase of treatment, we told the doctor no less than 3x that we could not afford the treatment out-of-pocket. The patient/insurance rep at the doctor's office called our insurance to make sure treatment was authorized and would be paid. They apparently told her yes, as long as our (in-network) PCP was listed on the claim. We also called the insurance co. ourselves and were told the same thing. We then moved forward.

About a month ago, we received an EOB from the ins. co. denying the claim for our visit in February of this year. We and the patient representative began a series of phone calls...we were again told by the ins. co., as long as the PCP is on the claim, they will pay it. The PR at the dr.'s office was told the same thing. We were both told this no less than FIVE times/separate calls. During one phone call (from us), the ins. co. looked up the RE, said that she's covered, then asked for our PCP, and in no uncertain terms said "Yes, absolutely, just have them put that name on the claim and it's covered, minus your deductible."

A week later, the claim was resubmitted. A few days ago (three weeks from when the claim was resubmitted), we received another EOB for the same visit that has been denied. For the same reason - "Your health plan does not provide benefits for these services when they are not provided by, or authorized by, a doctor or provider in your plan's network." We are now in the middle of treatment that we cannot afford, and the PR's explanation at this point is, "This happens all the time; it's probably in review and when review denies it, we'll start billing you."

The point is that we wouldn't have done this had they not said so many times that it would be paid. I know I need to start writing letters to appeal, but I'm not sure how to go about it. Should I just say what I laid out here?

I do wish we knew who we spoke to at the insurance company. DH isn't good about that, but they will only speak to him, as he is the policyholder (they told me). As an aside...I saw another of my doctors since this happened. That doctor is in CT and is NOT in the network. They paid that claim immediately

 

[Darcy03231]

I would see if the Dr. office has the names of who they spoke with. I would then file a complaint with the State's Board of Insurance.

 

[Lewisc]

It's not clear if the issue is with using an out of network provider or if your coverage for for the services you're receiving is limited by your policy. When your plan changes and your existing, network, doctor is not in your new network you typically have a limited (number of visits, period of time) in which you can continue to use that doctor, and receive in-network benefits for continuity of care.

You don't have notes. You need to talk to the insurance person at the doctors office. They should have notes. I'll speculate, without any real facts, your treatment exceeded what's generally allowed under continuity of care. You might be able to get your claims paid but maybe none in the future.

Second possibility. Your new plan has an out of network benefit with a very high deductible or your old plan had an out of network benefit but not your new plan.

Third possibility. Is your PCP practice associated with the specialist? I'm not sure how the endocrinologist can put your PCP name on the claim form as performing services if they're not in the same practice. Sometimes one doctor in a practice doesn't participate with every insurance. Billing can sometimes bill as if that doctor was covering for a participating doctor.

I'd play hard ball with the doctors office. You verified I had coverage. I expect you to take care of it. Obviously my answer would be different if you insurance lapsed due to non-payment or your policy changed from the date of the phone call and the date of services.

 

[kkandaj]

I do wish we knew who we spoke to at the insurance company. DH isn't good about that, but they will only speak to him, as he is the policyholder (they told me).

There should be a form your husband can submit to the insurance stating that you can talk to them about claims, etc. Ask your DH to contact them and ask about this. They may have this option also. Our children are on DH's insurance (I am on my own through my work) and after he submitted this form, I can now call and discuss any claims with them. DH doesn't ask as many questions and isn't as assertive as I am so it's best that I handle insurance in our home.

I hope you get this worked out. Our DS has medical issues and there have been several times that insurance hasn't payed because something is coded wrong, etc. I refuse to pay until it's corrected. There have also been times that I have told the hospital "I am not paying this bill until you guys figure out what is wrong." This sometimes takes multiple phone calls to the biller and the insurance company. I have learned to take notes on every phone call. I know how frustrating it is. Good luck!

 

[apirateslifeforme]

Just to add...

I'm looking at our plan benefits online right now...for these services, "no lifetime maximum/limit." "$25 copay per office visit" (normally it is $35 for specialists). Under "PCP Referral/Authorization?" it says Authorization. The entire plan itself has no deductible, except for ER and in-patient hospital service.

What I mean by putting the PCP on the claim is listing that she authorized the service. We did call her office prior to moving forward and yes, she authorized it. The patient rep at the RE's office called as well, got the authorization, and also obtained the NPI number in order to bill insurance. Come to think of it, while we were in discussion with the RE this past February, the patient rep called and said she'd just spoken to our insurance co. and we were all set; she gave them the PCP authorization and the insurance gave her an authorization as well.

Now the only thing I'm not sure of is whether there is out-of-network coverage. I can't find anything anywhere. But they must cover out-of-network; as I said, they covered the doctor I saw on March 13. She does not come up under "Find a Provider" on the insurance website, but they paid that claim immediately.

Ugh...I'm supposed to limit my stress, as my issue is exacerbated by it. This certainly isn't helping Trying to maintain my optimism, though...

 

[MickeyMom2Boys]

I just went through something similar related to a surgery I had back in September. I was told the surgeon was in-network before the surgery, then got a bill stating that I owed the full amount because the surgeon was not in-network and I do not have out of network benefits. I spoke to the surgeon's office. Apparently there was some sort of mix up when the surgeon relocated. They have to re-certify when they relocate and there was a mix up in the recertification. In addition, I got a bill for more than the original surgeon was charging from an "assistant surgeon". I wrote a letter of appeal for both claims. For the surgeon, I explained that I was under the understanding that the surgeon was in-network and provided all the details the surgeon had told me about the recertification process. For the second, I explained that I had no choice in choosing the assistant surgeon. Both were overturned and covered by the surgeon at 100%.

Write an appeal. Provide all the detail that you can. Explain that you called to make sure this was covered. Explain that the Dr.'s office called to verify benefits. Explain what you were told about the PCP being listed on the claim and that you made sure that they were listed. But do it now because there is a limitation on how long you have to file an appeal (6 months for me). It can't hurt! And make sure you send it with some sort of delivery confirmatino so you can confirm that they received it within the time limit. Good luck. I know how frustrated this can be.

 

[jmartinez1895]

Sometimes these types of things can take a long time to clear up because they involve so many different departments at the insurance company. we are still dealing with a claim that should be easy that is from 2011. Just keep calling and keep a log of everyone you spoke to, when a and brief summery of what was talked about. This has helped me out a lot.

 

[wiigirl]

Sometimes these types of things can take a long time to clear up because they involve so many different departments at the insurance company. we are still dealing with a claim that should be easy that is from 2011. Just keep calling and keep a log of everyone you spoke to, when a and brief summery of what was talked about. This has helped me out a lot.

This...plus if it comes to it, get an insurance lawyer. With the right information and paper trail a good insurance lawyer can get anything done.

 

[turtlebean]

I would definitely send in an appeal. Also you can ask the RE's office to appeal on your behalf. The more information you can send in with your appeal the better. If they got a prior authorization, then ask for that authorization number to include in the appeal.

If you are looking at your plan benefits and it does not tell you what your out of network coverage is, then you may not have any. I would also s/w your insurance company and if they paid one claim from your RE, then ask them to see if they are billing with the same tax id number. Doctors can have more than one and may be in network w/one, but not another. If they billed w/a different tax id number that is out of network, call the billing office and ask them to resubmit w/their in-network tax id.

 

[Sadie22]

File an appeal in writing. Phone calls do not count for much. When you do not have the name and title of who you spoke to and when, they count for even less. As credit card bills say, phone calls do not preserve your rights. You can get pre-authorizations in writing for procedures. Unfortunately that was not done and there's no record of what someone said on the phone. You need to create a record. Get referral forms from doctors to specialists or make sure they transmit the referrals electronically.

Other billing problems that can occur is when the billing/coder incorrectly codes a procedure. The doctor's authorization may not have been submitted correctly so that's another thing to sort out.

It can take a long time to straighten out. Good luck!

 

[taychase1015]

Definitely appeal the claim as soon as possible. I would also call back and ask to speak to a supervisor and if needed even a director. This sounds to me that someone is missing something in your claim when it was processed. Sometimes resubmitted claim may go in as a duplicate and not as an appeal.. I have worked Heath insurance for 20+ years.

 

[khaoskat]

I do wish we knew who we spoke to at the insurance company. DH isn't good about that, but they will only speak to him, as he is the policyholder (they told me). As an aside...I saw another of my doctors since this happened. That doctor is in CT and is NOT in the network. They paid that claim immediately

1) Their (the insurance company's) records will indicate whom you spoke to and have a general synopsis of the conversation. Often times these calls are recorded.

2) Have you pulled up their provider directory yourself to see if your doctor(s) are listed as in-network? If not, I would highly recommend doing so.

3) Have you received a copy of your benefits book or member handbook. Read it to see what it says about the type of treatment you are receiving.

4) Even though the policy holder is your husband, he CAN authorize them to speak with you. Furthermore, for them to speak to him regarding your medical problems/bills is a violation of HIPPA, unless you have specifically authorized them to speak with him about it.

5) Contact the Health Insurance Benefits Coordinator for your husband's employer and get them involved.

6) Another question - Is your PCP, since they are in CT, covered under your new MA plan? Maybe your PCP is not covered. But, I am thinking that this could go under "continuity of care" coverage, which is applicable for a certain period of time. I know when my insurance company broke their contract with the major local hospitals, that since I was already in care and was so far along, that it would be problematic for me to switch providers and hospitals so late, so it was still covered in network. So, I would also look under their "continuity of care". I am make the assumption that you are still with the same insurance company, but only moved to their coverage under the state your husband's employer is now in (MA vs CT).

 

[apirateslifeforme]

1) Their (the insurance company's) records will indicate whom you spoke to and have a general synopsis of the conversation. Often times these calls are recorded.

2) Have you pulled up their provider directory yourself to see if your doctor(s) are listed as in-network? If not, I would highly recommend doing so.

Before we even agreed to take this insurance, we looked at the provider directory. Our PCP was listed, but none of our specialists were. That's when we made our first call to the insurance company to see if we really needed to switch doctors, and we were told that as long as the in-network PCP was noted on the claims as "authorizing physician," we could still use our existing specialists.

3) Have you received a copy of your benefits book or member handbook. Read it to see what it says about the type of treatment you are receiving.

We never actually received a book, but all info is online. I pulled up the service three times in the past week and it is saying "No lifetime maximum/limit," "$25 copay per office visit," under "PCP Referral/Authorization?" it says "authorization," etc. It says nothing about in-network vs. out-of-network.

4) Even though the policy holder is your husband, he CAN authorize them to speak with you. Furthermore, for them to speak to him regarding your medical problems/bills is a violation of HIPPA, unless you have specifically authorized them to speak with him about it.

5) Contact the Health Insurance Benefits Coordinator for your husband's employer and get them involved.

6) Another question - Is your PCP, since they are in CT, covered under your new MA plan? Maybe your PCP is not covered. But, I am thinking that this could go under "continuity of care" coverage, which is applicable for a certain period of time. I know when my insurance company broke their contract with the major local hospitals, that since I was already in care and was so far along, that it would be problematic for me to switch providers and hospitals so late, so it was still covered in network. So, I would also look under their "continuity of care". I am make the assumption that you are still with the same insurance company, but only moved to their coverage under the state your husband's employer is now in (MA vs CT).

The PCP is actually in MA, and yes, she's in the network. She comes up under "Find a Provider," I have the provider ID, etc. I will also look under continuity of care; thank you to you and everyone else who suggested it. My only other thought at this point is that someone simply isn't filing the claim correctly, otherwise, why did they pay the other doctor? And they've paid for all the lab work I've had done as well (all in CT facilities)

I actually am not quite sure about the insurance co. being the same. When it was in CT, it was Anthem. Now it's Blue Cross Blue Shield of MA. But we always hear it called "Anthem Blue Cross Blue Shield." And on the BCBS website, when I click on "Find a Provider," the new window that opens has an "anthem.com" address I keep thinking about all the people in this company who are still located in the CT office, who live in CT and have CT doctors. Did they have to change to MA physicians for everything? That's quite an inconvenience.

We're also planning to speak to the patient representative in person as soon as possible. We're tired and stressed and we just need someone's help...Thank you to ALL who have answered and offered advice. I'll try anything at this point

 

[dhardawa]

Before we even agreed to take this insurance, we looked at the provider directory. Our PCP was listed, but none of our specialists were. That's when we made our first call to the insurance company to see if we really needed to switch doctors, and we were told that as long as the in-network PCP was noted on the claims as "authorizing physician," we could still use our existing specialists.


We never actually received a book, but all info is online. I pulled up the service three times in the past week and it is saying "No lifetime maximum/limit," "$25 copay per office visit," under "PCP Referral/Authorization?" it says "authorization," etc. It says nothing about in-network vs. out-of-network.


The PCP is actually in MA, and yes, she's in the network. She comes up under "Find a Provider," I have the provider ID, etc. I will also look under continuity of care; thank you to you and everyone else who suggested it. My only other thought at this point is that someone simply isn't filing the claim correctly, otherwise, why did they pay the other doctor? And they've paid for all the lab work I've had done as well (all in CT facilities)

I actually am not quite sure about the insurance co. being the same. When it was in CT, it was Anthem. Now it's Blue Cross Blue Shield of MA. But we always hear it called "Anthem Blue Cross Blue Shield." And on the BCBS website, when I click on "Find a Provider," the new window that opens has an "anthem.com" address I keep thinking about all the people in this company who are still located in the CT office, who live in CT and have CT doctors. Did they have to change to MA physicians for everything? That's quite an inconvenience.

We're also planning to speak to the patient representative in person as soon as possible. We're tired and stressed and we just need someone's help...Thank you to ALL who have answered and offered advice. I'll try anything at this point

BCBS is kind of a pain because they are actually many separate companies that roll up under one umbrella. It's very likely that this is a completely different company now since you changed states. But, the fact that you and the doctor's office were told over and over again that it would be covered and then it wasn't is the big issue. Sounds like they need someone to manually process the claim. It is running through their automated system and denying it, probably because it is an atypical claim and the system isn't built to handle that.

 

[kim929]

Ins. can be frustrating..... I called my ins to see if they covered a lift for inside my shoe, I was told yes, it covered 4 per year. I ordered the lift, ins denied it. I called they asked if I knew apx what day and time I called because all calls are recorded they would look it up and if the rep told me that, they would have to pay the claim. I know big difference but maybe they can do the same thing.
About them only speaking to your husband, if you were the one receiving treatment, they can't talk to anyone but you due to the Hipa rules.
I hope everything works out for you, you don't need more stress.

 

[danygirl]

here is a technique we have found to work well, especially if you are a woman and the insurance is your husband's

you call the insurance company and in a REALLY perky pleasant voice you start asking why your claim is denied. They will do the usual run around. You then say the magic words "I understand you can't help me, I would like to speak to a manager (ok, here is the magic) I DON"T HAVE ANYTHING ELSE TO DO TODAY (my mom tells them she is retired so she would love to be on the phone all day)EXCEPT TO GET THIS RESOLVED. I WILL JUST HANG ON THE LINE WITH YOU UNTIL YOU GET THE SUPERVISOR" Be super polite and perky and super pleasant and just keep asking to talk to someone who can resolve this.NEVER LET THEM PUT YOU ON HOLD. It scares them, they know you will just keep calling back all day long, and as long as you are sweet they can't get nasty with you. If you have names of who you talked to or dates you called, have that information ready and keep repeating it. Eventually they will get you to someone who can help you.

If not, then complain to the state insurance commission.

 

[jperrot1]

Insurance companies are always updating their computer systems, and certain types of claims just don't get processed correctly until done manually. I would suggest a written appeal which should require a real person to actually read and then process this claim properly. I'd bet money your claim will be paid. In the meantime just explain to the doctor's billing office that the claim is in limbo, and they should allow time so that you won't have to pay. Good luck.