what good is our health insrance

[fkj2]

Dh called the insurance company when he got home.

They told him the dr lied to us about being with our insurance company. There was also some other stuff that dh didn't explain to me on why they are not paying anything period. Tomorrow dh is calling the dr to find out how they made such a mistake and see what they are willing to do about their mistake.

I am still trying to find a way to get the money together to pay them, but short of not paying other bills I have no idea how to pay this.

It is your responsibility to check with the insurer about who's in your plan.

Having said that, I'd have a heart-to-heart discussion with the provider, and advise him/her that you're going to file a letter that details the misunderstanding in comunications with the state licensing board about his ethics. It may not totally get you out of the expense but hopefully, he'd negotiate payment down rather than have such an action on his professional conduct record.

 

[dburg30]

Having said that, I'd have a heart-to-heart discussion with the provider, and advise him/her that you're going to file a letter that details the misunderstanding in comunications with the state licensing board about his ethics. It may not totally get you out of the expense but hopefully, he'd negotiate payment down rather than have such an action on his professional conduct record.

Even if they waive the fee for some reason, and it really wasnt the OP's fault at all, you should still write a letter letting them know this. Now, if there is some underlying issue that you are partially at fault for, then you really cant blame the Dr. fully.

I know that I had a hernia operation about 10 months ago, and I'm glad I have insurance . About $16000 'retail' in bills later, and all that left my pocket was about $350 I'm happy.

 

[aclov]

I always do a double-check with asking if a doctor is in-network. I go online to the provider directory or call member services and ask the dr's. office. There have been situations were maybe the facility or most of the dr's. are contracted but maybe one is not so you get stuck paying out of network. Sounds crazy but it happens.

As other's have asked - do you have a deductible, was this a coinsurance, what is the reason code on the Explanation of Benefits for denial.

You can make payment arrangements. I ended up in the emergency room and I have a high deductible so my responsibility was about $1000.00 I've made payment arrangements with the hospital. I've also have done this with dr's. office. Don't stress yourself out about getting the $300 up front, they will work with you.

 

[Toby'sFriend]

Our insurance company just sent us a letter saying that they are establishing a free 1-800 helpline staffed with "Nurse Assistants" (read not even real Nurses - Nurse Assistants) to answer any and all health questions I may have.

Uh no thanks. That isn't what I want from my Health Insurance. I have a DOCTOR that I use to answer all health questions.

What I would like from them however is that when I have a kid wake up at 2:00am on a Sunday morning when the regular Doctor isn't available with a 103+ degree temp that doesn't respond to Advil and claims he is having difficulty breathing and I take him to the Emergency Room - THEY PAY THE HOSPITAL BILL the way they are supposed to instead of trying to claim "oh, that really wasn't all that medically necessary."

 

[aclov]

A nurse line is cheaper than a dr.'s office visit or emergency room visit. For you and your company. That's why insurance companies now have those.

Remember that all those claims experience will play into the premiums that your company and you will end up paying.

 

[Toby'sFriend]

Well of course it's cheaper for the insurance company to pay a "Nurse Assistant" to read some information off of a medical database to me over the phone than to pay a Doctor to examine, diagnose and treat.

Hey you know what would be even cheaper than that? They could just point me toward WebMD.com or require me to ask the DIS Community Board for a diagnosis.

 

[aclov]

It's funny that you mention coming on the DIS to get a diagnosis, because I have seen posts like that on here. Most of the responses are "go to the doctor!" I personally wouldn't ask a forum for their medical interpretation. But there are medical professions on here that may be able to provide some insight.

The 24/7 Nurseline that we are getting next year says to call if your uncertain what to do especially at night or on the weekends with problems such as cuts or burns, sore throat, fever, headaches.

I ended up in the emergency a few months back with a kidney stone and was in so much pain I could barely register at the hospital, in that instance there's no way I would call a Nurseline.

 

[arb34@mchsi.com]

Hate to highjack the thread, but I too am having problems with insurance. They are refusing to provide coverage for a prescription for antidepressants for 10 yr old DS who was born with Meth in his system and spent 2 years in foster care before I adopted him.
We have experience with the dire staights a child with these issues can get in to if left untreated as we were there a year ago with the 12 year old half brother who suffered even more neglect and abuse in his first 4 years. He currently takes 8 different meds but is doing the best he ever has emotionally.
I just cannot believe that an insurance company can override the advice of the very Psychiatrist that they are paying for these children to see. I guess I will just pay for the med out of pocket, but who do they think they are anyway? (Sorry, I'm venting)
Anyone have any experience or advice?
TIA

 

[DonnaDuck]

My insurance sent me a letter that they were denying a claim b/c dr. wasn't in network. I knew he was and called the insurance company back and they admitted he was and resubmitted the claim. I mentioned it to doctor and he said they do that ALL the time. Look at your list of providers, see if the doctor is listed.

This exact same thing happened to us a few months ago. We received a $500 out-of-network bill from the Dr that was working in the ER when my husband was taken. We paid the bill, but decided to call the insurance company to find out why he was out-of-network, since he was the Dr on call at the ER, he shouldn't have been. Our insurance company (Cigna) made the Dr. in network and resubmitted the claim. We got a check for the money we paid a few weeks ago. Apparently this does happen all the time. I can't help but wonder how many people pay it, not knowing that all they have to make is one phone call to get it changed.

Good Luck.

 

[jackskellingtonsgirl]

Hate to highjack the thread, but I too am having problems with insurance. They are refusing to provide coverage for a prescription for antidepressants for 10 yr old DS who was born with Meth in his system and spent 2 years in foster care before I adopted him.
We have experience with the dire staights a child with these issues can get in to if left untreated as we were there a year ago with the 12 year old half brother who suffered even more neglect and abuse in his first 4 years. He currently takes 8 different meds but is doing the best he ever has emotionally.
I just cannot believe that an insurance company can override the advice of the very Psychiatrist that they are paying for these children to see. I guess I will just pay for the med out of pocket, but who do they think they are anyway? (Sorry, I'm venting)
Anyone have any experience or advice?
TIA

Contact the drug company and see if they have a program where the meds are free if you can't afford them. I think it is "compassionate use" or something. Also talk to the psychiatrist and see if there might be a generic that could be prescribed to keep your costs down. There are a lot of programs to help offset the costs of prescriptions, it just might take some research.

 

[aclov]

Hate to highjack the thread, but I too am having problems with insurance. They are refusing to provide coverage for a prescription for antidepressants for 10 yr old DS who was born with Meth in his system and spent 2 years in foster care before I adopted him.
We have experience with the dire staights a child with these issues can get in to if left untreated as we were there a year ago with the 12 year old half brother who suffered even more neglect and abuse in his first 4 years. He currently takes 8 different meds but is doing the best he ever has emotionally.
I just cannot believe that an insurance company can override the advice of the very Psychiatrist that they are paying for these children to see. I guess I will just pay for the med out of pocket, but who do they think they are anyway? (Sorry, I'm venting)
Anyone have any experience or advice?
TIA

Do you have a summary plan description or benefit booklet? You may be able to appeal the claim. Unfortunately, if it's a self-insured plan they can cover or exclude certain services. For instance, I have no infertility coverage or marriage counseling but another self-insured plan might decide to cover it. With a HMO plan there are certain state mandates that the insurance company has to abide with. We're going through insurance change and the insurance company recommended we don't cover therapy for mental retardation. I couldn't believe that, and I voiced my opinion to them and my boss that it was pretty harsh. I mean that's something you have no control over, if you feel your 2 year old should speak like a 10 year old, that's a different story but not covering speech and physical therapy in that instance is heartless. It does it very frustrating dealing with this stuff.

 

[WendyisDarling]

Hate to highjack the thread, but I too am having problems with insurance. They are refusing to provide coverage for a prescription for antidepressants for 10 yr old DS who was born with Meth in his system and spent 2 years in foster care before I adopted him.
We have experience with the dire staights a child with these issues can get in to if left untreated as we were there a year ago with the 12 year old half brother who suffered even more neglect and abuse in his first 4 years. He currently takes 8 different meds but is doing the best he ever has emotionally.
I just cannot believe that an insurance company can override the advice of the very Psychiatrist that they are paying for these children to see. I guess I will just pay for the med out of pocket, but who do they think they are anyway? (Sorry, I'm venting)
Anyone have any experience or advice?
TIA

Is it a specific drug they are denying? If so, they can probably give you their preferred alternate drugs. I know that stinks. Some alternate drugs our ins. has suggested for DS are very different than what he was prescribed. I think sometimes your doctor can make some sort of plea to the insurance company and explain why that exact drug is needed. (A few years ago a doctor did that for me). These days, I don't know...our ins. for prescription drugs is awful. They keep putting more and more meds on their "non-preferred" list, which requires a $45 co-pay.
My best advice is call insurance company and get the list of drugs they will approve that they think are comparable. (I'd like to know who decides this). Then call DS's doc and see if any of the alternate drugs are appropriate. If no, tell the doctor your ins. won't cover it and ask for advice and if there is anything he/she can do. Maybe at the very least you can get some samples. If all else fails, call the pharm. co. and explain the situation and ask if they offer any programs.
Good luck.

 

[EthansMom]

Here's what I would do:

Doublecheck the doctor's participation in the insurance at the insurance company's website, if possible. Also, your denial letter should tell you the information needed to contest their decision. Even if the dr. is out of network, you should be able to negotiate a partial payment.

Discuss the insurance company's issues with the doctor's billing office and work out a payment plan while you contest the insurance company's rejection. If you can send even $5 or $10, it lets the office know that you do intend to pay the bill.

Good Luck!