Insurance issue- watch out!

[fatelk]

Health insurance has been a big frustration for us. I consider myself fairly competent when it comes to understanding things, and my wife worked in the medical field for many years and dealt with insurance, billing, diagnostic codes and such as part of her job. So I'd like to think that we are perhaps above average in understanding and wading through the system.

Why is it so unbelievable difficult, nigh on impossible, to avoid "out of network" and "not covered" issues? The latest issue for us has to do with some orthotics I needed from the foot doctor. He says it's likely I'll need surgery eventually, but these should help for the near future (they have). He gave us all the diagnostic billing codes beforehand so we could make sure it's covered.

My wife called the insurance, gave them the codes, and was told that absolutely they would be covered for me. She even asked them to double check due to the cost (over $500). She was assured that they would be covered. Now we get an EOB showing that they were not covered. She called the insurance, even gave them the name of the person she talked to originally, and was told no, it would not be covered, and that the original rep she talked to had been mistaken. Too bad, tough luck.

How far does a person have to go with this kind of thing? She even wrote down the name of the first person who had said yes, date and time and what she was told. She did her due diligence and it still wasn't enough.

I won't even go into how our insurance has changed this year in ways that will cost us several thousand dollars; that's a "whole 'nother story".

Also, I'm just venting some frustration. This isn't intended in any way to be a political thread. I know health care and insurance can get political real fast but that's not where I was going with this. Just a heads-up to watch all the little details anytime you're dealing with doctors and insurance companies. Get everything in writing if you can. I told my wife maybe we need to record any phone conversations with them too, tell them "This call may be monitored or recorded for quality assurance purposes." :)

[shoot-n-lead]

Health insurance has been a big frustration for us. I consider myself fairly competent when it comes to understanding things, and my wife worked in the medical field for many years and dealt with insurance, billing, diagnostic codes and such as part of her job. So I'd like to think that we are perhaps above average in understanding and wading through the system.

Why is it so unbelievable difficult, nigh on impossible, to avoid "out of network" and "not covered" issues? The latest issue for us has to do with some orthotics I needed from the foot doctor. He says it's likely I'll need surgery eventually, but these should help for the near future (they have). He gave us all the diagnostic billing codes beforehand so we could make sure it's covered.

My wife called the insurance, gave them the codes, and was told that absolutely they would be covered for me. She even asked them to double check due to the cost (over $500). She was assured that they would be covered. Now we get an EOB showing that they were not covered. She called the insurance, even gave them the name of the person she talked to originally, and was told no, it would not be covered, and that the original rep she talked to had been mistaken. Too bad, tough luck.

How far does a person have to go with this kind of thing? She even wrote down the name of the first person who had said yes, date and time and what she was told. She did her due diligence and it still wasn't enough.

I won't even go into how our insurance has changed this year in ways that will cost us several thousand dollars; that's a "whole 'nother story".

Also, I'm just venting some frustration. This isn't intended in any way to be a political thread. I know health care and insurance can get political real fast but that's not where I was going with this. Just a heads-up to watch all the little details anytime you're dealing with doctors and insurance companies. Get everything in writing if you can. I told my wife maybe we need to record any phone conversations with them too, tell them "This call may be monitored or recorded for quality assurance purposes." :)

And, might need to get approval, in writing and with listed approved procedures.

[Greg S]

I would re-submit 2 to three times. The jokers I deal with always deny then the second or third time they come around. Review the policy of what is/is not covered and re-submit with the paragraph and line number and the conversation with their representative. My daily maintenance scripts are cheaper outta pocket than with insurance and it is a PIA to get 90 day fills as I travel for work alot for 21+ day at a time. Their arguement is refills by mail but you can't get them forwarded to another addy (were I'm working at) so it is futile.

Where is that blasted emoicon pounding against a brick wall.

[fatelk]

And, might need to get approval, in writing and with listed approved procedures.

Apparently the issue in my case was a clueless insurance rep. The second insurance person today told her it would only be covered if I was diabetic (I'm not). The first person had told her otherwise. She said that she specifically remembered that the first insurance rep asked (among other questions) if I was diabetic. My wife told her no, I was not, does it make a difference? They told her no it does not make a difference, and that it was covered, no approval or anything needed. Very clear, no doubts, no misunderstanding on my wife's part. The second rep today just said that the first rep must have simply made a mistake and misread our policy. Tough luck for us.

So yes, in the future we'll go the extra step of requesting it in writing. Even at that I wonder though. If you get misled by a clueless insurance rep what recourse do you have? Apparently none.

Also, my employer hasn't given us a copy of the policy for years. It's available online only and is difficult to decipher and understand as such. They tell us that the best thing to do if something isn't clear is to call and ask. :(

[Skunk1]

Been battling health insurance for the last 2 years. There's no win, I think they are above god. Had 3 hospital visits 2 years ago. Got out from that and got the forth a few months ago when the daughter tore up her finger. Argue all you want they need the money more than you. Back to digging out from this one. I'm glad everyone has insurance but it's killing my middle class life as my price and deductibles seem to double every year.

[fatelk]

I'm glad everyone has insurance but it's killing my middle class life as my price and deductibles seem to double every year.

I'm right there with you on that one! It's getting pretty crazy. I literally worry how I'm going to pay my mortgage in the future. My wife especially hates insurance companies. She says their job is to figure out how to NOT pay for things.

[Nazgul]

Last time I had an out of network problem, I said to come and retrieve the CPAP machine and I refused to pay any fees. I was assured it was covered when I applied for it.

They figured it out in 24 hours and covered it.

Appel it as noted by others, they may change their mind.

Don

[runfiverun]

wait till you get your car insurance bill.

[jsizemore]

Call your state attorney's office and insurance commission and file a complaint. A lot of the ins. providers will say no just to see if they can get away with not paying. What have you got to lose? Intentionally mislead about coverage is against the law in most jurisdictions.

[Hick]

What jsizemore said. My wife had a problem with a surgery that was needed for her health but that her insurance company said was not needed. My insurance (her secondary) said they would pay if the first one wouldn't. In the end, we called the State Insurance Commission and they told the first company to pay (and they did).

[xs11jack]

Insurance companies have no morals.
Ole Jack

[snowwolfe]

Dont pay the bill, screw them.

[leeggen]

My wife had fallen and boggerd her ankle up. Went to the ER and then the follow up with the doc couple days later the ins. had refused payment. When we called and questioned the comp. they said her policy was to become active at midnight of the day after she was hurt. Even the ins. comision went along with the ins.comp. We were 8 hours away from the start date. If we had known that ahead we would have waited. Ins. is just a legal theft ring that we were forced into.
CD

[shoot-n-lead]

Dont pay the bill, screw them.

It is a legitimate bill...not the Dr.'s fault that the insurance didn't pay.

[duckey]

I hope everything works out for you. Just out of curiosity what issue(s) do you need orthodox for? I have Plantar Faceites (prolly not spelled right) in both feet. I am allowed two inserts a year that cost the Gov't $500 a pair....I am active duty. The company that makes em says he can sell em to me for $250 a pair when I retire and have to pay for em outa pocket. Scammers! Never been told I need surgery...yet.

[lightman]

My insurance went up and my coverage went down after I retired. My Wife had a minor surgery the first of last year. We were told that it was pre-approved but it was later denied. We fought it for the whole year, repeals, AG's office, Insurance commission, everything we could do. We finally just paid it. It was minor surgery but it was not a minor cost! When we used up all of our options we ask the Dr's office what they would settle for, without hurting our credit, and they reduced the bill a little. We paid it, mainly because we received the service, but it sucks to go through that.

[MT Gianni]

My wife especially hates insurance companies. She says their job is to figure out how to NOT pay for things.


That sir, is the essence of the insurance business. Figure maximum income and minimum outflows.

[MaryB]

File a complaint with your insurance board. If they said it was covered they have to cover it. If they get to many filed complaints they lose the ability to do business in your state so they usually settle on your side for small stuff like this!

[RogerDat]

Can't say as I'm surprised. The Hospital can't get the bill anymore than sort of semi accurate. Insurance company can't afford to pay for the care you paid premiums to them for.

The horror stories abound. But the one that gets me is when I showed up at a large ophthalmology practice with branches all around the area. One eye swollen almost shut, bloodshot as all get out and they said, we can maybe get you in Thursday (it was Monday morning early, I waited since they don't have weekend hours) when I questioned the long delay they said that was when the doctor was in that office and available.

I asked where the doctor was so I could drive there, they were not sure how they could do that, would have to call, and see. My parents brought me up to not hit women but it was a bit of a challenge to hold to their teachings for a moment there.

I couldn't decide if I felt more like human cattle, or the burger they become at the fast food place. I'm sick, need doctor, what ever happened to the idea of treating sick people? Buggers should be required to make house calls for 6 months every year just to keep their license.

[johnson1942]

some insurance companys give a hard time to discourage the people they insure so they drop the claim. studies have shown that companys that do this sort of thing save 15 percent of there payouts every year. call the insurance comm office of your state or seek legal help.

[tomme boy]

Had the same thing happen a long time ago. I talked to our HR lady then to the person that actually does the insurance through the company. The company insurance lady took care of it for me.

[elk hunter]

Guess I'm lucky, last year my health insurance company stepped up big time for me. Of the $292,000 the Dr's and hospitals billed I paid $2500 and no hassles. Over the six years I've been insured with this company the few items not covered haven't amounted to more than a few hundred dollars. I guess not all insurance company's are the same.

[mac1911]

one thing that i have learned is it really matters not what anyone says over the phone.
Get names, ID numbers , transaction numbers and request a written document on the coverage you are seeking.
We had to fight for nebulizer machines we didnt even want. The hospital basically said take them home they are paid for anyway through your insurance.... a few months later we get billed for 1500$ for 2 cheap neb machines and another 300 in tubs and mask.
All of which was provided to us through the hospital in emergency room. Kids had a major asthma attack brought on by flu.
our insurance "claims" all emergency room visits and needed material are cover for our kids with a 200$ fee?
The fight was that our kids where admitted later after the emergency room recomended they stay for observation and pump them full of fluids and antibios until the flu passed....3 days. which we paid $0 for????

[snowwolfe]

It is a legitimate bill...not the Dr.'s fault that the insurance didn't pay.

I dont care. Had the same thing happen to me after neck surgery. Before the surgery a nurse brought over some type of electric stimulus machine for me to use after surgery 30 minutes a day. Told the nurse I would only accept it if she was 100% sure my insurance (Tricare) would cover the cost 100%. She said it would. I also called their head office and they said no charge to me.
6 weeks later got a bill for $3,500 for that "machine". Told them the story and I wouldnt pay it. Never heard another word abut it.

[popper]

Plan providers change frequently, coverage should not. Congress changes the payout every year so providers drop from the plan often. TPA (billing group) is basically a call center, get coverage in writing for planned stuff. We also get to cover those who won't buy insurance so premiums go up. Congress won't change it so good luck.

[garym1a2]

Make the doctor/hosp get the pre-approveal first. My hospitial said they did not need it with my insurance. The insurance claims (3 Cat scans, 2 Mris and a Pet scan). I got a 54K bill last June. My brother battled them for 6 months till the bill was paid by insurance. We now inist on approvals before any new tests.

[popper]

Make the doctor/hosp get the pre-approveal first They used to, not much anymore. Cancelled Frontier service last month, got a $3.04 credit. Called today and told I would get a bank card in 6 mos., cost more to process than it's worth. Had an EkG,chest xray, cat in the ER last year, got a bill for $600. Called and they said it was misbilled - haven't heard from them - haven't gotten an EOB for it yet..

[fatelk]

Dont pay the bill, screw them.

Its a small private practice and the dr was very clear beforehand that I should verify the coverage. Besides, I called and told them what happened and they were understanding, said the "cash price" is about $200 less, so that's a good thing. My complaint is with the insurance co, not the doctor.

We'll make a strongly worded appeal, but I expect we'll just end up paying. Lesson learned. We thought that calling to verify was due diligence, but clearly not. In the future we'll get it in writing.

On the positive side the the orthotics do help, quite a bit actually, so it's not a total loss. I have a big bone spur and some arthritis. Surgery was a real option and the insurance would have covered it completely. Ironic.

[woodbutcher]

:twisted: I have a sure fire method for proving what I am told by an insurance company.I record all calls to and from the insurance company.Had to take one to court one time.Brought the recording,and played it after their lawyer pretty much called me a liar in front of the judge.Needless to say the fur hit the fan.
Insurance company paid the bill in full.$16,000 and change.
Good luck.Have fun.Be safe.
Leo

[Duckiller]

How much is the bill? Time to get some legal advice. If amount is small got to small claims court. Large amount , talk to lawyer for real. I believe the insurance co. is bound by the "Yes you are covered" even if the rep made an error. Also go to Insurance Commision and Attorney General as well as Better business bureau. Insurance may pay to make you go away and clean up their record. Insurance co. has a procedure for claims disputes ,use it. You did reasonable due diligence. It is the insurance co. responsibility to properly train their employees.

[Echo]

I'm right there with you on that one! It's getting pretty crazy. I literally worry how I'm going to pay my mortgage in the future. My wife especially hates insurance companies. She says their job is to figure out how to NOT pay for things.
I mentioned to my lawyer son-in-law (ex-, now) that I heard that law school mainly taught lawyers how to evade the law, and he agreed...

[Ken in Iowa]

Recording conversations is not a bad idea. Just make sure that there are no restrictions in your state!

Most call canters record conversations themselves. The date, time and representative name should be all that is needed for them to retrieve it.

I have used orthotics for years. They're one of the best investments that I ever made.

[tomme boy]

As long as you tell them you are recording that is all that is needed in most states. Every state is different on who and what you can record.

[BigMagShooter]

I'd do one better, I'd record the conversation. Nowdays it's easy to get voice recorders to record phone conversations. All you have to do is tell them this conversation is being recorded, or not, depending on your state. :)