insurance people. geez.

[Beha]

So I have had no problem getting my insurance to pay most of the tab for my recent PVR but they are stubbornly refusing to pay for my pre op CAT scan. They keep insisting that I should have had an MRI instead and they will only pay for MRI's despite letters from 2 different of my doctors stating I can't have MRI's because of the hardware I have in my back.

I almost want to get an MRI next time I need a scan and break the machine and my back and make them pay for every cent and sue them for screwing up (ok not really but If the economy keeps going the way its going I might get desperate for a settlement ).

I'm going to keep fighting...these people are just idiots. geez.

 

[hall]

I could be wrong, but I don't remember many people saying they had a MRI before surgery. Those are very expensive! I will put it this way, I did not have one, not for the heart. They do not make any sense. You can dispute the claim against the insurance company for refusal to pay. My gosh can't they read? You can't have a MRI. I would certainly dispute it. Best of luck

 

[Lisa in Katy]

It is interesting that the payor has taken this stance, but there could be many reasons. Did you have a Cardiac Cath, or was the CT Scan instead of a Cardiac Cath? Was it outpatient or inpatient? If it was outpatient, how long before surgery was it performed? It depends on how the hospital is paid, but many contracts would include pre-op testing in the inpatient rate. It's all inclusive. If it's just the procedure they are questioning, it must have something to do with the type of plan you're on.

FYI - There are those of us on this board who are employed by insurance companies, so topics such as "idiot insurance people" kind of raises our hackles!

 

[BackDoc]

first off a CT scan is significantly less expensive then an MRI. 2nd with the wires you have, you can't have an MRI--no one will perform one. and if you did, you still couldn't sue anyone because you consented knowing you shouldn't have one--you are negligent.

3rd: a pre-op CT scan should not be considered as part of the "total procedure", and should be seperately reimbursable.
Now if you are dealing with an HMO-that could be a horse of a different species.

It would seem to me that a simple letter of medical necessity from your surgeon would be all that is necessary.

Follow the appeals process as stated on your insurance EOB denial.
Good luck.

 

[Guest]

Go through the appeals process, talk to the billing office who processed your CTscan, and see what they can do. They should be chasing the insurance company but we always end up doing their work for them.

Also make sure the correct ICD9 codes were used in billing. Pre-op, I had an ekg done at my primary docs office as part of my physical, my insurance felt that it was unnecessary, they said routine ekgs were not proven to be a beneficial part of a physical, so it was denied.

I fought back and forth with the insurance that I had a heart issue that required an ekg. The doctor's office used the wrong ICD9 code, all they had to do was correct it, rebill, and then my insurance covered it. Took them awhile to get it all taken care of.

 

[ALCapshaw2]

You've got to get past whoever takes the call and get to a Supervisor or someone who actually has the authority to say YES, we will cover it.

You could start by asking to talk with a supervisor.

If that doesn't work, ask their 'Medical Examiner' (or whatever they call such a person) to contact your Surgeon so that they can talk "Doctor to Doctor". That usually resolves these kind of disputes.

 

[Lisa in Katy]

As one of the "idiots" or "brain dead zombies" who work for an insurance company I can tell you that the majority of the issues that get to my desk (I'm the 3rd level) are caused by provider errors - codes, not following protocols, etc. Most claims are auto adjudicated. As long as the approvals are in place, humans never touch them. The majority of claims are paid correctly. I pulled a report for a major hospital today that submitted over 33,000 claims to us in 2008. It took the hospital on average 32.4 days to submit a claim. It took us on average 8.2 days to process a claim. Of those claims, 256 had to be resubmitted for various reasons, including provider errors. The rest were paid correctly. Of course all I hear are the complaints about the less than 1% of claims that had to be resubmitted, again many due to provider errors. No one ever says "we appreciate that 99+% of the claims were paid correctly."

Here's an example of what could have happened based on my experience. The hospital called to get approval for the MRI that the majority of patients might have in your situation. When you got to the hospital, they realized that because of your special issues, they had to do a CT. The hospital never corrected the approval. Therefore, the claim is denied. In any case, the hospital should be appealing the claim if they want to be paid. You shouldn't spend a moment on the phone or pay a dime.

And BackDoc, there are many contracts that include all preadmission testing in the case rate. That is the way that CMS (Centers for Medicare and Medicaid Services for those that don't know) sets the reimbursement for hospitals - any testing done in the 3 days prior to admission are included in the inpatient MS-DRG. Many commercial contracts use the same logic. This is all taken into account when they set the weight for the MS-DRG and the conversion factor. I negotiate hospital contracts Monday-Friday so I know what I'm talking about.

Just like I don't appreciate being called an "idiot", I don't appreciate being called a "brain dead zombie".

 

[Lynlw]

Lisa, FWIW MOST of the problems we've had with insurance over the years have been the hospitals fault and not the insurance. Usually they get our number wrong, or use the wrong code or wait a year to submit a claim ect. of course in 20 years and 10 surgeries as well as other inpatient stays there have been a couple insurance errors but for the most part insurance tells me what the hospital/doctor's office did or didn't do and what to tell them to get it fixed.
I did get annoyed when a year after one of Justin's surgeries they sent a letter from BSBC third party collection where they explained that they are not responsible for claims caused by dog bites, airplane ,bus accidents and a few other things like that, so please call to find out who they can bill for the
third party claim. so I called and said my son's heart surgery was not caused
because he fell, was in an airplane crash or a dog bit him. She said well it
does say heart and sometimes they are because of accidents.


I hear you on the job insults, I used to work in a lab for years and drew blood so bite my toungue alot. I appreciate all the help you give about insurance questions and sorry people didn't take your first nice hint.

 

[BDMc]

Lisa and Lyn, I just lost a reply to your posts I spent an hour writing. Please don't be offended by someone venting their frustrations here. Lisa, I really appreciate your educating us on how a competent person handles the claims, and for sticking up for the job you do! I have had bad experiences with both providers, and insurance companies. There is a plague of carelessness in the world today. It is in every business and industry, and at all levels. But thank God it is not everybody! It is "a war out there". I say, a battle between good and evil, but perhaps that is a stretch. In any case, I take it you are on my side. Keep doing the thorough job you do, but know many do not. The only insurance company people I can get a last name from when I call are for auto insurance. I am just a waiter and bartender, yet my name tag has not merely my real name, but first and last. It is my commitment to myself to take responsibility. I make mistakes all the time. I work crazy hours sometimes, (Have worked 87 days without a day off, and over the years every hour of the day). I sometimes say things I shouldn't, but I accept the consequences. I have saved 3 people from serious injury or death, one incident would not have happened if management had listened to me. I battle all the time just to try to be sure we fulfill our contracts and obligations, and this is at what I consider the best company of it's kind! It's late and I'm losing focus, but please don't be offended by this type of venting. The presentation of your experience/side of it is a great service, and an example of what makes this site great.

 

[Lisa in Katy]

Brian, It's not the venting that bothers me, it's the name calling. These are people attempting to do their jobs the best that they can with the resources that they have. Remember, the first level employees solve the majority of problems that come their way, but they can't overturn correct decisions, no matter how loudly the member or provider screams. There is a process that has to be followed.

I get the same answer about no last names when I talk to the front line employees within my own company. One reason is that these people don't get paid enough to deal with hate mail. Another reason, at least in my company, is that we offshore parts of Customer Service. (Don't get me started!) In many cases, the first names aren't even real. There seems to be a plethora of Brads, Angelinas, Monicas, etc. Wonder why??? However, if you write down that you talked to Brad P., it will work for future phone calls. In my company, they are working to bring Customer Service back to America, but it's going to take some time and money.

I've been in the healthcare business since 1985, other than a seven year stint in teaching, and have been on all sides of the issue - patient, business manager for a physician group, low level hospital administrator, contractor for a managed care company, and contractor for a major hospital - and believe me, everyone likes to blame everyone else. You know that saying about "Be careful when you point your finger because there are always three fingers pointing back at you." How true!

 

[hensylee]

So I have had no problem getting my insurance to pay most of the tab for my recent PVR but they are stubbornly refusing to pay for my pre op CAT scan. They keep insisting that I should have had an MRI instead and they will only pay for MRI's despite letters from 2 different of my doctors stating I can't have MRI's because of the hardware I have in my back.

I almost want to get an MRI next time I need a scan and break the machine and my back and make them pay for every cent and sue them for screwing up (ok not really but If the economy keeps going the way its going I might get desperate for a settlement ).

I'm going to keep fighting...these people are just idiots. geez.

tell them your uncle, the lawyer, said they have to pay it. no joke.....

 

[Beha]

I'm not saying ALL insurance people are idiots but these two women I've been dealing with are. And not just because of the issues I've been having getting the CT covered, these people can barely speak english, i'm not kidding! I didn't mean any offense to all those non idiots who work in the insurance field- I'm sure you guys get alot of grief you dont deserve.
My dad (who is also my lawyer) has taken over the fight

 

[hensylee]

many of our banks, ins companies, etc send their stuff offshore for handling. I hate that because when you call, you are talking to India or some bumfoo place like that. Bet you were talking to a whole other country!

That happened to me once when I was trying to get info on stocks and the girl didn't have a clue as her english was so bad! she asked me for the tracer number of something I had dropped in my mailbox and sent. that clued me in she was not on these shores.

Best wishes.

 

[wcasey5]

As one of the "idiots" or "brain dead zombies" who work for an insurance company I can tell you that the majority of the issues that get to my desk (I'm the 3rd level) are caused by provider errors - codes, not following protocols, etc. Most claims are auto adjudicated.

For the majority of us, we don't know 1st level from the 5th level of hell. We call, expect results, get nothing. What you are saying is that we have to ask for this? Why doesn't the people we call know this? As far as the idiots go, I think its more of an endictment of the system than the people who work in it. I know I have called and realized that these people are just doing their job. But it is easy to mistake stupidity for ignorance. They don't know what the issue is and its not in the best interest of insurance companies to find out.

As long as the approvals are in place, humans never touch them. The majority of claims are paid correctly. I pulled a report for a major hospital today that submitted over 33,000 claims to us in 2008. It took the hospital on average 32.4 days to submit a claim. It took us on average 8.2 days to process a claim. Of those claims, 256 had to be resubmitted for various reasons, including provider errors. The rest were paid correctly. Of course all I hear are the complaints about the less than 1% of claims that had to be resubmitted, again many due to provider errors. No one ever says "we appreciate that 99+% of the claims were paid correctly."

Isn't that the insurance companies job?

Here's an example of what could have happened based on my experience. The hospital called to get approval for the MRI that the majority of patients might have in your situation. When you got to the hospital, they realized that because of your special issues, they had to do a CT. The hospital never corrected the approval. Therefore, the claim is denied. In any case, the hospital should be appealing the claim if they want to be paid. You shouldn't spend a moment on the phone or pay a dime.

Unfortunately, its in the insurance companies best interest to deny the claims. I find it hard to believe that an insurance company person would be allowed to take a call from a customer, admit fault, and take responsibility for resolving the problem. When the resolution costs the company money. It would be fabulous if it would happen, but that is just not realistic in the U.S. system. IMO it just won't happen unless you fight. PITA!

Just like I don't appreciate being called an "idiot", I don't appreciate being called a "brain dead zombie".

I can understand that! Its not fair. But from the outside, we don't understand that we have to fight for what we are owed, or why.

I think your insights are valuable to negotiating U.S. health care. Thanks

 

[KristyW]

Unfortunately, its in the insurance companies best interest to deny the claims. I find it hard to believe that an insurance company person would be allowed to take a call from a customer, admit fault, and take responsibility for resolving the problem. When the resolution costs the company money. It would be fabulous if it would happen, but that is just not realistic in the U.S. system. IMO it just won't happen unless you fight. PITA!

WCasey,

I work in the dental field and submit insurance claims for a dentist. Lisa is exactly right...if "I" as the provider (dentist, doctor, hospital) do not submit a claim with the correct codes for the procedures done, the claim will NOT be paid. It is MY job to make sure everything is in order. If I submit a claim with the incorrect code, I cannot get paid...even with a phone call to the insurance company. I must submit a CORRECTED claim for that to happen. EVERYONE who works in this capacity should know this.

You are right, we as patients shouldn't have to chase this down..it is the providers job.

 

[Tbone]

I have an approximatly $13000 USD bill outstanding with the hospital from 1-18-08. My insurance company tells me it's all paid. I go back & forth and am ready to pull hair This problem is the simple fact that all (I forget the term) agreed upon prices have been paid. This happened before but was only a couple of hundred, and went to collections. I paid it. I know that was wrong to do but what else am I to do when my credit rating comes into it?

Whishing it gets worked out.

 

[ChouDoufu]

i had a problem about 10 years ago after having some testing done. at the
time i had a real job with real bc/bs insurance. a month or so afterwards,
when i thought all had been properly handled, i started getting bills for
what should have been covered....which was stated in fairly clear language
in the insurance contract.

called bc/bs, explained the situation. they said it's a coding error, and i'd
have to call the doctor to have it corrected. what's the correct code?
sorry, we're not allowed to give that information to non-providers. so called
the doctor, explained the coding error. they asked what's the correct code?
i said bc/bs won't tell me. they said sorry, you have to provide the correct
code if you want us to refile, we're not responsible for providing the
corrected codes. back and forth we go for a couple months.

as it turns out, i was doing contract engineering at the time, average contract
around six months, working all over the us. lots of moving, lots of change of
address, lots of lost mail. after each move would call both sides, still
nothing changed. this went on for several years, finally got bored with it,
notified both parties i was no longer interested in playing. they can figure
it out.

soon enough it was sent to collections, which i ignored. it did show up on
a credit report a few years later, but didn't seem to have any affect on
my credit score. wonder what the status is now?

current insurance is pretty worthless, especially now that the provider
switched from an australian to an american carrier. i went ahead and put
in a claim for january's avr.....not really expecting to have anything
covered, just who knows, maybe they might reimburse a small percentage.

going as expected, everything is denied. but the reasons seem to be
pulled out of their....elbows. have sent several emails questioning the
denial, each time the service rep chooses another exclusion at random.
but then each time i explain why that exclusion doesn't apply, they
have a different rep respond with another arbitrary exclusion. it's like
they don't bother to read anything i send...at least no more that the first
couple words, which allows them to select a boiler-plate denial message.

i understand it's their job to deny claims, and the more ignorant they
seem, the easier it is. i'm sure most people just give up after a while,
and that's what they're hoping for.

 

[Lisa in Katy]

It is not the patient's job to fight these battles. As I, and others, have said before, it is the provider's job. If they are under contract, they are required to hold the member harmless, meaning the member shouldn't be billed for the provider's mistakes. However, sometimes they will bill anyway and hope the member pays. It is not the insurance company's job to tell the provider or the member the codes. In fact, in most states it is ILLEGAL for the insurance company to tell the provider which codes to use. If the provider doesn't know what they are doing, they need to hire someone that does.

Here's what you, as a patient, should do. This applies to those with managed care plans that have contracts with the chosen provider. If the plan does not have a contract with the provider, most of this doesn't apply.

#1 Know your policy. Know what is covered and not covered (in general). Know what your copay or coinsurance is. Know how your policy works as far as in and out of network, and know which providers are in network. Know what types of services require authorization and remind the provider if you are having one of these services.

#1 1/2 (because I forgot it and don't want to renumber). Always carry your card with you and give it to the provider when asked. The provider only has a certain number of days to file a claim and if they miss this deadline because you didn't give them the necessary information, you can be held responsible for the entire bill.

#2 Pay your copay or coinsurance up front only if that's what your insurance says to do. Don't let the provider bully you into paying more than you are supposed to. Save your receipts.

#3 As the bills arrive, match them with a receipt, and save them. Usually the first bill is just a notification that they have filed a claim. When you receive an Explanation of Benefits (EOB), match it up with a bill. The EOB shows you the total amount billed, the amount paid, the amount written off, and what is your responsibility.

#4 If you haven't already paid the portion that is your responsibility, pay it as soon as you are able.

#5 If the provider bills you for more than your responsibility, do not pay them. They are hoping you will, but don't fall into that trap. Call their office and tell them that you are looking at your EOB and according to your insurance company, you have already paid what you owe. They have a copy of the EOB so ask them to look at it with you. If they continue to bill you, let your insurance company know and the provider will be mailed a balance billing letter explaining the contractual obligation.

#6 Do not let the provider or the insurance company put you in the middle. It is the provider's job to know the contract and the policies and the insurance company's job to make sure the provider has access to this information.

#7 That's it.

wcasey - Every state and area is different, but in today's world, the majority of companies are self-funded, meaning the employer is actually the one paying the claim. The insurance company is not the payor and therefore does not benefit by denying claims. In most states, there are penalties for inappropriate denials and delayed claims. In Texas, we are required to pay a clean claim within 30 days. A clean claim means that the authorizations are in place and the codes are correct.

 

[Lisa in Katy]

Yes, wcasey, it is the insurance company's job to pay the claims correctly the first time. That doesn't mean that it's not nice to acknowledge someone for something that they do well. Doesn't your boss or customer ever tell you "Good job" or "Thank you."?

I haven't had a claims issue in years. Why? Because I follow the steps above. For instance, when I went to see my Cardiologist last year, they said that I needed to pay the total bill ($300-$400) at the time of service because I hadn't met my deductible. I explained that my employer pays the first $500 of my deductible and I still had over $200 left. She showed me what she was looking at online and it clearly stated that I had an $1100 deductible and had only met a little over $200. However, the next line down clearly showed how much was still in my account. I actually only needed to pay them about $80.

BTW - Thank you to whomever took the offensive words out. I appreciate it.

 

[wcasey5]

Yes, wcasey, it is the insurance company's job to pay the claims correctly the first time. That doesn't mean that it's not nice to acknowledge someone for something that they do well. Doesn't your boss or customer ever tell you "Good job" or "Thank you."?

I appreciate that you have a thankless job, and yes it is nice to get a thank you every once and a while. I feel like people in the insurance industry are just as much victims of the system as the rest of us. If I had a problem that was obvious, and had an insurance worker tell me that they would take care of it, pay, and I wouldn't have to worry about it. I would give them a big thanks. Unfortunately, not many situations seem to occure that fall in that circumstance.

But I will give you a big thanks for providing the information here. Thanks!

I haven't had a claims issue in years. Why? Because I follow the steps above. For instance, when I went to see my Cardiologist last year, they said that I needed to pay the total bill ($300-$400) at the time of service because I hadn't met my deductible. I explained that my employer pays the first $500 of my deductible and I still had over $200 left. She showed me what she was looking at online and it clearly stated that I had an $1100 deductible and had only met a little over $200. However, the next line down clearly showed how much was still in my account. I actually only needed to pay them about $80.

The steps are logical, and puts a large burden on the patient to follow up. The reality is, that if I am checking the doctors to make sure they are doing their job, and I have to keep track of all my parameters (co-pays, deductibles), what exactly do I need the insurance company for? It seems they are just a middle man.

wcasey - Every state and area is different, but in today's world, the majority of companies are self-funded, meaning the employer is actually the one paying the claim. The insurance company is not the payor and therefore does not benefit by denying claims.

Sure they do, its reduces costs for the company who hired them to be the middle man. If they want to keep the account, they will reduce the costs to the company as much as is legally possible. I believe the company I work for is self funded, which basically means that I don't really have insurance at all, just BC/BS as a figurehead on the card I get. They also just make up dollar figures to get the employees to pay a percentage. The more we pay, the less they pay.

In most states, there are penalties for inappropriate denials and delayed claims. In Texas, we are required to pay a clean claim within 30 days. A clean claim means that the authorizations are in place and the codes are correct.

If everything went as it was intended, nobody would complain!


Unfortunately, I see this thing collapsing in a similar way that the financials did. It will be a mess! I really hope I'm wrong!


Again, Thanks!