My insurance company is denying the claim. What do I do?

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My insurance company is denying the claim. What do I do?

I was with someone at the doctor's office when the insurance company was called. The insurance company told the doctor's office that the procedure was covered. I didn't get anything in writing. After the surgery was performed, to the tune of $23,000, the insurance company is denying the claim. It was a sinus surgery and they are saying that I didn't have insurance coverage long enough and that it was a pre-existing condition because I had had sinus infections in the past. I can't pay for this - I was told by the doctor's office I would have to pay my out of pocket maximum - $2000 - which is quite different from 23 grand. Please help. I don't know what to do.

sarah314

Here's the problem...

When the insurance company informed your doctor that the surgery was covered under your policy, the answer meant "yes, this type of policy covers that type of surgery."

However, if you have unique circumstances (such as a pre-existing condition), that always trumps the "is this covered?" call.

That's why a customer service rep giving a benefit quote will *always* give the disclaimer that the information is subject to your benefits and eligibility at the time services are rendered. (Or say something similar to that.)

Did you have continuous health insurance prior to this policy beginning? If so, check to see whether you can submit proof of prior creditable coverage to get the pre-existing clause waived.

Otherwise, unfortunately, the bill is your responsibility. See if your doctor can work out a cash price for you - just because the billed charges are $23K doesn't mean they can't work out a discount with you.

mbrcatz

OK, it's pre-exisiting. That "is this procedure covered" call is NOT a guarantee of coverage.

You can always appeal the decision - but likely you will lose an appeal. If you disclosed the sinus problems, it's probably excluded from your policy. If you didn't, it's still a pre-existing, after they found out about it. You can't sneak in and figure a pre-approval nullifies your ommission.

Your best bet is going to be to call the hospital and providers, and ask them to reprice to a cash price. Likely, this is going to end up costing you about $5K if you do that.

Lori S

When a doctor gets a benefits quote (verbally) it is never binding. The claim must be received and processed with all the medical documentation before that determination can be made. Your only option here, is to make a cash deal with the doctor and make payments.

Of course, if you and your doctor feel this is not related to previous sinus infections, but something totally different, you could follow the guidelines in your policy for an appeal.

s351chic

If a Dr. calls for benefits and is told something that is later recanted by the insurance there isn't anything you can really do because as the member its your job to know your benefits.
Now, if YOU called and were misquoted the insurance is more likely to overturn the denial because you tried to get the correct info. There is no way the benefit booklet your employer gives you will show you every scenario which you can encounter. They are very vague so be sure to call in yourself before having work done.
If they find 100% against your claim the best bet you have is to try to negotiate with the dr and hospital BEFORE you are in collections. Let them know your situation and that you are paying cash. I am a claims processer/adjustor for BCBS and you'd be surprised how hospitals write off sometimes half of what they bill just because of their insurance contract. They may be able to knock a percent off your bill (not half.. but anythings better that the full bill).
As for the Dr bill if they are asking for $2000 out of pocket then your insurance must be picking up any of his fees over the $2k. Is the $23,000 just for the dr??
Take solace that once your OOP Max has been reached for the year you have no coinsurance or deductibles for the rest of the year (be it benefit or calender)

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