Negotiating the back and forth between insurance and doctor billing

[maddythebeagle]

Anybody have any good online resources for consumers...stories .I am having a heck of time with a specialist that is covered under my PPO....some of it has been denied by the insurance company for double billing and lack of "pricing information"....this doctor does have pretty hard to follow billing.....Havent had problems with getting other doctor bills paid....

[mykidslovedogs]

I deal with claim issues a lot in my business and try to help work through difficult claim issues for my clients. One of the things I have discovered is that (particularly with surgeries), if the surgeon tries to bill extra, for example, for an assistant surgeon, the carrier may deny the assistant surgeon cost as an "incidental" claim. In other words, the carrier thinks that the cost of the assistant surgeon should have been billed right along with the procedural code for the surgery itself, and the insurance carrier feels that that cost should have been part of whatever their negotiated rate with the provider was for the entire surgical procedure. In cases like this, it is sometimes necessary to file a formal appeal asking the carrier to review a letter of medical necessity from the doctor in order to get the claim paid. It's just a procedural step that can really be a pain in the neck, but oftentimes it is well worth filing the appeal. Instructions on how to file an appeal are always included at the bottom or somewhere in the text of the EOB (explanation of benefits), but a lot of people panic when a claim is denied and try to skip the formal appeals process by trying to work directly with customer service, which can actually prolong the process and make things worse.

You can kind of compare the above situation to getting your car fixed...just like you expect that the cost of the repair is the quoted cost and that you aren't going to get charged extra for parts that the mechanic forgot to order after the fact, the insurance carrier expects to pay only the negotiated rate, and they are typically unwilling to pay extra for things like assistant surgeons, when that type of cost isn't typically included in the negotiated rate for that particular service. So, in a case like that, an appeal with a letter of medical necessity is usually necessary.

Let me give you an example of how a provider once tried to abuse charging insurance carriers for the cost of an "assistant surgeon". What happened was, the surgeon was using the surgery room as a place to train interns, and then they were turning around and charging the insurance companies for the extra cost of having an "assistant surgeon" in the room. It didn't take long for the insurance carriers to wise up to what was going on, and now, that is why we sometimes see insurance carriers fighting over paying for those extra costs now. Usually, to fix the problem just requires an appeal along with a letter of medical necessity now. It's an extra step for the patient, but if the abuse had never happened in the first place, we probably wouldn't be in this boat of having to fight back and forth on situations like this.

Now sometimes, the carriers deny claims as "duplicates" if the insurance carrier finds a claim in the system for the same exact procedural code, date of service, and billed amount as one that has already been paid. This can sometimes happen when there is bad timing and a provider has resubmitted a claim after a claim has already been paid. If you ever get a claim that is denied as a duplicate, you can call the insurance carrier and find out when the original claim was paid and you can also ask them to provide you with the amount that either was applied to deductible, coinsurance or copays (if applicable).

[youbet]

Quote:

Originally Posted by mykidslovedogs Let me give you an example of how a provider once tried to abuse charging insurance carriers for the cost of an "assistant surgeon". What happened was, the surgeon was using the surgery room as a place to train interns, and then they were turning around and charging the insurance companies for the extra cost of having an "assistant surgeon" in the room.

I went through this kind of thing. I had knee surgery a few years back. When I was wheeled into the operating room, the orthopedic surgeon I expected to be there introduced me to his "assistant." During the surgery (I was fairly awake since I had a spinal instead of general) I was aware that the assistant was the one working on me with guidance from the surgeon that I had expected to actually do the work. Hmmmmm......

Well, things came out OK as far as the surgery goes. But, I was surprised when there was an assistant surgeon charge on the bill. So was my insurance provider, who refused to pay. I appealled and lost. So I told the assistant surgeon's billing people that I felt my surgery did not require an assistant surgeon and that I wasn't going to pay. They said fine and I never heard from them again. No struggle, no threats, just quickly took it off the bill.

I've notice the information book my insurer publishes now has almost a whole page devoted to assistant surgeon charges and when they will and won't pay them. Apparently they were having the issue come up frequently.