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insurance company vent
Old 09-19-2012, 05:00 PM   #1
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insurance company vent

I could either scream, cry, or eat a large carton of ice cream. Just received a letter saying that because the ct scan was not pre-certified, insurance will not pay the $3800. Last year it was the colonoscopy that they said they would not pay. We successfully appealed that one. So this year, I called to see if that needed to be pre-cert. and was told no. Then I get this letter denying the ct. Do they just pick one thing each year, preferably, an expensive one, to decide to deny? Now I'm in a panic about the small surgery to remove the "suspicious lesion" from my bladder. What if they decide they don't want to pay that? I was delighted it turned out, on removal and path, not to be malignant. I may end up paying 15K just to find out all is well.

I guess the big lesson is to call the insurance company before every d**m test is run to be sure they can't weasel out. After all, it might be their new denial item for that year.
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Old 09-19-2012, 05:31 PM   #2
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I wanted to be sure that my colonoscopy was covered by BCBS so I wrote them a letter asking for confirmation one month before the procedure was scheduled. I received an answer - thankfully yes - one month after the procedure was done.

So, I kinda feel your pain.
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Old 09-19-2012, 05:40 PM   #3
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I guess this illustrates the importance of getting confirmation in writing or by email where possible and otherwise asking that the conversation be added to your record and keeping good records of who you talked to, when, what they said, etc.

One would think that if you are using in-network providers that they would know the rules, what needs to be pre-certified and what does not and would obtain the pre-certification where it is needed.

Good luck with your appeal. If your appeal is denied and you did work in-network then I would press the providers to provide a substantial discount for failing to get pre-certification before doing the ct scan - they need to take some responsibility for their role in the process.
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Old 09-19-2012, 05:44 PM   #4
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My SIL has a small brain tumor that is very slow growing.
Her neurologists monitored it annually with a CT scan, and after more than 10 years decided it was growing enough that it was time to do surgery.
She got a second opinion. (Brain surgery isn't something you just say "sure!!! Go for it!!") That Dr. agreed.
She went through ALL of the precertifications for the surgery. It was approved. She arranged for disability, etc for the follow up time.
All her ducks were in a row.
A week or so later, on the same day she gets the news that they didn't get it "all". She is called by her insurance company and told they're denying coverage.

Obviously she appealed. But it was an INCREDIBLE amount of stress to put on someone who was recovering from a serious surgery and had just gotten news that the problem wasn't solved.

It took 2 months for the insurance company to back down. Despite her letters from them showing it was pre-approved.

Insurance companies can really suck.
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Old 09-19-2012, 05:59 PM   #5
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That sounds ridiculous rodi. Perhaps if there was some sort of punitive damage where an insurer unjustly denied a claim they wouldn't be so cavalier about issuing denials. The only problem is that they would probably then fight tooth-and-nail on appeal or in litigation.
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Old 09-19-2012, 07:47 PM   #6
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Rodi, that sounds so wretched that...well, I don't even know what to say. Poor woman!
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Old 09-20-2012, 06:05 AM   #7
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Palomalou, do not give in on this. Check your phone records for the date and time you called. Filing an appeal with the exact date and time of the call helps your case. You should also file a complaint with your state insurance regulator. Insurance companies do these things because the penalties are few and the potential rewards significant.
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Old 09-27-2012, 04:59 PM   #8
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It has pretty much worked itself out--they will pay $2900 out of $3800. I'm happy!!
But just sad to hear of Rodi's SIL. My mother was finally killed by mets to the brain, seeded all the way through. It was very difficult.
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Old 09-27-2012, 05:57 PM   #9
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Every time I read or hear something like this I imagine a group of insurance company CEO's, kneeling down in front of the Congress begging them "Please, please, please regulate us more and more! Make us process more and more bureaucratic red tape! Please!!"
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Old 09-27-2012, 06:06 PM   #10
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Quote:
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It has pretty much worked itself out--they will pay $2900 out of $3800. I'm happy!!
Good this is working out well.
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Old 09-27-2012, 07:41 PM   #11
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I would call your state insurance regulator. The have people there to help and advise you for such matters.
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Old 10-07-2012, 09:49 AM   #12
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It has pretty much worked itself out--they will pay $2900 out of $3800. I'm happy!!
But just sad to hear of Rodi's SIL. My mother was finally killed by mets to the brain, seeded all the way through. It was very difficult.
Why do you owe $900? It's less than $3800 but should you be paying $900 according to your plan?
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