Originally Posted by BUM
I'm getting ready to battle the bastards tomorrow. No real biggie, but this this could be good training for me.
I recently went to see a neurologist I had seen a few years ago. His receptionist said they didn't take my insurance but they would submit a claim anyway and I should just pay the copay, and we'll see what happens.
Well Aetna denied the claim and it looks like I'm stuck with the $250 bill minus the copay. I pay about $400 per month (as a single) for this coverage
On a PPO, "out of network" claims usually apply to the out of network deductible. If your plan has an out of network deductible, you are likely going to be responsible for the bill as per your contract with the insurance carrier. Do you have a copy of your contract? I would take a look at it before you make your appeal. You might be wasting your time. If it is an HMO, then it probably would have required prior authorization before visiting the specialist. Again, this would be per contract, so if you didn't get prior authorization, then you are probably going to be responsible for the bill. The premium you pay for your insurance is based on your current contract. I can't say this without sounding offensive, but, IMO, it is your personal responsibility to know your contract BEFORE seeking services.
Knowing that your provider didn't take your insurance, you should have called in advance to find out what you could have expected with regards to coverage.
I don't understand why people automatically assume the insurance company and it's employees are "bastards" when people technically should have understood what they were buying when they bought it. When you bought that policy, and agreed to pay $400.00/month for it, I would be very surprised if the contract didn't specify that you were to use "in-network" providers and facilities in order to receive the best coverage. Most insurance companies do not provide "indemity" (any doctor) policies without charging a much higher premium.
It's usually pretty hard to get the insurance carrier to make an exception to the contract that specifically spells out how out of network services will be covered......Then again, I have made appeals before and have been successful, particularly if there were no "in-network" doctors in the servicing area that could provide the same services that you needed...