Insurance companies, what a racket.

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dixie_belle

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I've had all these procedures this year, right? Biopsy, partial mastectomy, radiation, the list is endless. I'm starting to get the explanation of benefits now. Anthem has denied my surgery. So I call them and I ask why. They originally said the doctor's office didn't pre-certify the procedure. So I call the doctor's office. They said they called the insurance company and were told that the procedure they were going to do didn't need pre-certification. So I call the insurance company back. Now they say they are not paying because the doctor's office did pre-certify but they used the wrong code. They said they were doing one procedure and then when they billed the insurance company, they used a different code. So I called the doctor's office back and were told that they pre-certified and billed the same code.

So someone is not telling the truth. And I'm going to have to pay for it. Sigh. I can't fix this sort of thing, I haven't the slightest idea what codes they use or if something needs to be pre-certified. But I did tell the doctor's office that if they couldn't fix it, they weren't going to get paid. I called the insurance company prior to having the partial mastectomy and told them at that time that I would be having a procedure. They asked me what was the code.......like I would know. Normal people do not have access to medical coding. Someone somewhere made a mistake and it's going to end up costing me a bundle.

So now I wait for the doctor's office to talk to the insurance company, but I gotta tell you, it doesn't look good.

And I'm supposed to have this $3500 deductible, where I pay the first $3500 and then everything else is covered at 100%. So I get an explanation of benefits on all that radiation and the insurance company is only paying half of the bills. Um.....I've already met the deductible way back when I had the original biopsy. So I had to call them....again and ask what the heck is going on. The rep said, "well, you have to meet your deductible". I had to remind her that I did that already. Oh yeah, she says, I see that. I'll make a recommendation to review your claim. Um....review it? How about pay it?

Hubby and I pay a lot of money for private health insurance. We picked this plan with Anthem because if we needed something major, it would only cost us $3500. Now they are not paying? What's with that? I'm so angry.

Ok, I had to vent. I'm sooooo angry.

I shouldn't have to be spending an entire afternoon on the phone. I'm not asking for anything other than what we've been paying for. And I'm so frustrated because calling does no good.
 
So sorry your dealing with all of this, it is the last thing you need right now. I have to say IMHO I think the health care act should be scrapped and caps should be put on pharm. companies and hospitals based on what they can charge.
 
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Here in Delaware we have a State Insurance commissioner.Not sure if every state has 1.It is an elected office.This is just the kind of things they often handle.Get all your info together and give them a call.Try your elected officials-senator or representative for your area.Give them a call.They are elected to help you.Maybe they can steer you in the right direction.Hope you can get things resolved.Insurance companies are no fun.As long as you are giving them money they are nice-when you ask for something it is a different story.
 
My Uncle is an MD and his Office Manager is his wife an RN. She said to me something one day that has changed the way I look at this problem ever since.

'Why is it OUR job to figure out how YOUR insurance works?'

I sympathize with you and your difficult situation and I hope your health is improving. But I am sure you are capable of figuring this out whether it takes more phone calls, a visit to your insurance agent or a report to your State oversight agency. Don't get frustrated, get determined. Do not leave something this important to a secretary at your Dr.'s office are the person at the Insurance Co. call center. Take notes on every conversation you have and demand everything in writing so you avoid the he said/she said conundrum.

Good luck.

Dr. Taylor
 
Do not give up, try again requesting your doctor's office to reapply using the correct code, keep asking until they do it. I have a lot of experience because of my husband's fragile health and bills, and that deductible mixup can be a bummer. Keep calling, and good luck for a successful outcome.
 
Wow! That stinks
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I know. As a "regular" person, when we have some sort of procedure, there is no way I could know what the correct procedure code was. But I did call the insurance company a week in advance telling them I had breast cancer and that I was having a procedure to remove it. Evidently there are many, many codes for this sort of thing, and it depends on exactly what the doctor does.

So I finally called my surgeon's office and told them point blank that they had three options available: 1) fix this with the insurance company (2) do a retro pre-certification and get approval or (3) write it off as unrecoverable because I wasn't paying a single penny......period.

I'm not paying for a billing error on my doctor's part. I did what I was supposed to. I called my insurance company prior to the surgery. I called my doctor's office prior to the surgery to make sure they had received precertification. In fact, I called them twice because I feared just this sort of thing happening. It is up to the doctor's office to precert for the correct procedure because only they know what that procedure code is. I cannot fix this....only they can. And if they can't, well, too bad, so sad. No money for you.
 
Good for you--you are right, it is up to the doctor's office to make sure that the billing is done correctly (and the pre-certifying too)

I agree it is not up to the doctor's office to figure out anyone's insurance, but it is up to them to make sure that they do their paperwork accurately, and in a case like this when there is a discrepancy in codes (supposedly) then only the doctor's office can confirm the correct codes with the insurance company.

It's entirely possible that someone at the insurance company entered the wrong code--it happened to me on a drug claim--much less money involved obviously, but still annoying when a prescription drug that should be covered is denied. They told me I was approved for one drug number but the pharmacy dispensed a different one, which was not covered. I double checked with the pharmacy--they had dispensed the correct drug with the correct number--turns out someone at Blue Cross had entered the other number--no idea how the person pulled that number out of the hat, it wasn't even similar to the actual one. The drug info was submitted again and Blue Cross finally got it fixed and paid my claim.

Hopefully your issue is something similar--seems likely, considering the conflicting information you have been given every time you have called the insurance rep!! It's not a good sign when from one call to the next they keep changing their reasons for not paying--and they will get your claim paid soon.
 
First and foremost Miss Dixie, I am so sorry that you have yet another "mafia" mob to deal with specific to your "insurance" company. (Though I still have a hard time considering any entity that can require a very hefty "deductible" and STILL with a straight face call it "insurance", um well, credible....) I will pray that you continue to fight them with logic and grace.

Secondly, The State insurance commissioner only works for you, the lowly peon citizen, as an after thought and as a line for public consumption.

He or she came from the insurance industry and will return to the insurance industry when done with their primary duty. That being, protection of State assets. Just as it is not a police officers duty to protect you, likewise the I.C., D.A. and ect. is not there to protect you either. While you "may" get some action, I sincerely doubt it.

Thirdly, I concur that the Health "mandate" should be scraped! Contrary to popular belief, the supremes NEVER ruled on its constitutionality. If you believe so I recommend you read the case, um all of it. What the nefarious supremes ruled on was a tax issue and further ruled against we the people in doing so. To date and to the continual shame of the republicans and old school democrats, the Constitutionality of this takings is STILL not being challenged. Now they ARE still examining the minutia of the "mandate" but NONE of them is stepping back from that minutia to truthfully and lawfully declare it's patent and obvious unconstitutionality. If it is unconstitutional on it's face, move no farther and examine no portion of "it", period.

Lastly, and for the non liberty minded, the most scary notion ever,..... Buckle yer seat-belts and prepare for horror cause after all it is the "high" holiday of halloween... What would happen if both gov. and "insurance" companies were taken out of the picture entirely as existed before world war 2? OMGoodness, told ya it was truly scary, right? Well horsefeathers! A growing number of Docs all over the country are returning to that very model that worked so well for century's. They do NOT accept any kind of insurance and gov interaction (if they can help it) and guess what. This is the scariest part,..... they are able to actually spend TIME with their patients (horrors) and they charge ALOT LESS FOR THEIR SERVICES! Additionally, because they are NOT slaves to the industry and government, they can practice true healing instead of the AMA "bandaid but still dying" shtick. This follows one of the repub. talking points that is actually true, well, even if they don't practice it. If you want to drive the price of something down, get government OUT of it! And then you foster competition by severely limiting what a corp. is allowed to do (Read the founding fathers on the topic of corporations, I triple dawg dare ya) and ESPECIALLY how big you let them become.

I'll go ahead and channel my bfe and say, A nation if ignorant wimps, we have become. (dude, he's Yoda, he CAN"T be wrong)

My earnest prayers for your will-power and good outcome Miss Dixie,

Bb
 

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