Medical Insurance Question

[Kori Ellis]

Last month, I went to the hospital and had a test done. When I got there and checked in at the desk, they said, "We already called and got approval from your insurance company for the test. Your portion is $45." I said, "Okay, I'll pay it now, but I have a secondary insurance as well." They said, "Oh, then we'll bill the $45 to your second insurance and send you the bill if there's a balance."

I went along with it and had the test.

Last week I got an explanation of benefits statement from my primary insurance company saying that they denied the claim because they decided the test wasn't covered (necessary??) on my policy.

Today, I got the nearly $1000 bill to pay for it.

So .. do I have to pay it? They told me when I got there that they had already gotten approval from my insurance company.

???

Thanks.

[Aggie Hoopsfan]

I'd call your group coordinator and talk to them about it. Our group coordinator is awesome and knows every hole in the system to help us out.

Also contact the secondary and see what they can do for you as a backup.

[mouse]

663-1125

Ask for Ruth, she works in that department.

[Kori Ellis]

I'd call your group coordinator and talk to them about it. Our group coordinator is awesome and knows every hole in the system to help us out.

Also contact the secondary and see what they can do for you as a backup.

It's not a group situation. I'm an independent contractor - I have individual insurance through Unicare. I pay over $300 per month. I think that since they pre-approved it, they should have to pay for it.

[T Park]

I have unicare too.

I got shot down when I went to do some stuff at Texas Med Clinic.

Crooks.

[Aggie Hoopsfan]

Damn, that's some bullshit right there.

I'd probably backtrack it through the hospital to see who they got approval from. If they got a fax or preapproval number I'd think that your insurance co. would have to pony up

[Kori Ellis]

If they got a fax or preapproval number I'd think that your insurance co. would have to pony up

Yeah, I'm thinking they have to have that. Otherwise, if they didn't, I was supposed to pay up front before I had the test done.

[MannyIsGod]

Talk to the people at your hospital specificaly the person who told you it was preapproved. Hopefully they have some form of documentation that it was approved that way you don't have to cover any portion of the bill.

But usually you have to pay for those tests up front, so if they give you any grief about it ask them why that procudure wasn't followed. You may have to fight a lot, but you shoudln't have to pay for these services. Call your agent, they should be able to offer assitance as well.

In fact, before you do anything else, call them. Get them to do some of the leg work for you. Thats what that agent is there to do.

[E20]

Phuck, that is classic phuck up.

[boutons_]

"they have to have that"

Yep, there must be a paper trace, or computer trace at the hospital. But good luck on finding it. The hospital gets paid from your or the insurance, and may not give a shit about YOUR problem.

In useless hindsight, you should have asked for the proof of insurance payment from the hospital rather than just verbal.

For-profit medical care and for-profit insurance will fuck you over every chance they get. Successufl fuckovers are a profitable activity generating $Bs.

[Kori Ellis]

In useless hindsight, you should have asked for the proof of insurance payment from the hospital rather than just verbal.

I don't think I would ever think to do that. They weren't supposed to do the procedure unless I paid for it up front or they got approval from the insurance company. It says that on my paperwork.

That's why I think I don't have to play. This hospital/clinic's policy is that you have to pay upfront if they don't have a guarantee of payment from insurance.

[MannyIsGod]

Boutons doesn't know what he's talking about. The hospital will have the records on file if they ever recived it. They need that shit to get paid.

[Kori Ellis]

Well they had it when I was there because they even had it down that I would have to pay only $45 of it. So hopefully it's a simple process to get it cleared up. I hate crap like this.

[MannyIsGod]

Yeah, it really is a pain in the ass. I sorted out things like this back in my agent days all the damn time. Most of the time it was incompetent hospital staff. Either way, your agent should take care of it for you. Thats what they get paid to do.

[leemajors]

even if you do end up not having to pay for it, the insurance company will probably keep sending you bills for it. if you are talking to them on the phone, try to get to a manager and get his/her name as a reference if you have to keep calling back. i considered unicare when i got new insurance for my daughter and i a few months back, but decided to go with bcbs tx instead.

[MannyIsGod]

even if you do end up not having to pay for it, the insurance company will probably keep sending you bills for it. if you are talking to them on the phone, try to get to a manager and get his/her name as a reference if you have to keep calling back. i considered unicare when i got new insurance for my daughter and i a few months back, but decided to go with bcbs tx instead.The insurance company shouldn't be billing her for anything. The bills come from the medical provider, not the insurance company. If they denied the claim, they're done with it from their end.

[iminlakerland]

Hey Kori,

Fight it all the way, the same thing happened to my mother when she had a referal number from her insurance agency and they sais her co-payment would be 50.00. We all know full well when you go in to see your doctor and have tests run you have to pay them upfront when you get there to check in.

You should also request what tests were performed, the doctors office may have performed some tests that they hadnt informed you about and are now billing your insurance agency.

Is the Hospital billing your or the insurance agency? If it's the hospital you should call your insurance agency and find out what is going on. My moms insurance agency actually wrote a letter stating all the statutes and the hospital finally stopped billing my mom.

[RashoFan]

I would have to say if you were preapproved you should not have to pay. I would think that they should be a reference number/preapproval number in regards to your doctor's visit/tests. However there may be a "disclaimer" on the paperwork from the doctor's office that states if insurance will not pay(for wahtever reason) you are responsible for the bill. Let me know if you need me to kick somebody's ass for you...
:makemyday

[Das Texan]

call the insurance company and bitch at them for a few hours, accuse them of sending you the bill and then demand they take care of it for you today. I mean thats what the fuckers in California do every single day, because you know, every piece of paper is a bill even if its not from us and even if it says THIS IS NOT A BILL.


But seriously, they should have documented evidence at the hospital with something showing the authorizations they had received. If they can produce this paper trail you are in good shape. If all else fails, have them send you a formal denial letter from the insurance company themselves or whomever gives the approvals and then follow the appeals process set up by your insurnace company. Its going to be a pain in the ass if it comes down to this, but sometimes you just have to do it. But first see if the facility can get it corrected for you, since you know they kinda fucked up to start with.

[Shelly]

Kori, it's very possible that the hospital coded your test incorrectly also. That's happens a lot and if it was the wrong code, they will kick it right back.

[SequSpur]

Preapproval is not guaranteed, check the small print.

Unicare is not a traditional health insurance so if you can find something else, do it quickly. Try some BCBS plans, or Humana One... if you need a number to a broker, let me know....

Shelly is right, they could've coded it wrong...

[SequSpur]

Preapproval means a phone call to check if your insurance is current and the hospital is in network.

[Kori Ellis]

Preapproval means a phone call to check if your insurance is current and the hospital is in network.

No - in this case my insurance told them that it was approved. They even told them which portion wasn't covered ($45 -- that wasn't a co-pay). It says right on the paperwork that if it wasn't approved that I had to pay up front. They would not do the test without the money or approval.

[Kori Ellis]

Preapproval is not guaranteed, check the small print.

Unicare is not a traditional health insurance so if you can find something else, do it quickly. Try some BCBS plans, or Humana One... if you need a number to a broker, let me know....

Shelly is right, they could've coded it wrong...

What do you mean it's not "traditional health insurance"? By what everyone has told me, it's the best possible insurance for me. BCBS has no coverage for some of the stuff that Unicare has already covered for me.

[Kori Ellis]

have them send you a formal denial letter from the insurance company themselves or whomever gives the approvals and then follow the appeals process set up by your insurnace company

I already have a denial letter from the insurance company in the form of an explanation of benefits letter. I got that before I got the bill from the hospital. There's an explanation of the appeals process on the back.

[2Blonde]

Like sequ said. I have always been told that preapproval is a guarantee of benefits, not of payment. Usually upon that guarantee the facility will accept what they estimate you will have to pay after insurance pays their part, as a gesture of good faith. This does not negate your obligation to pay the debt if insurance fails to pay. On the other hand, like Shelly said, things get mis-coded all the time. I have had claims that have needed to be resubmitted 3-4 times before the coding was right for the system to accept it. Also, even if your primary insurance denies it. your secondary insurance may pick it up and pay most or all of it. And if your primary insurance denies it maybe it will go towards your deductible if it was after the first of the year. Althought it doesn't sound like it since you've already gone a couple of rounds with the insurance.
Ask for a case manager at your insurance company. Usually you get better service that way. It's usually an RN who will look over your file and determine if your tests are necessary. If you don't get help there you can file an appeal with the insurance company.

[Kori Ellis]

Thanks 2Blonde.

Whatever the case is ... The test was necessary. Plus, my doctor's office told me my insurance approved it days before I went to the hospital. The hospital told me that my insurance approved it when I arrived. And perhaps I would have opted to put off the test if they made me sign anything saying that I had to pay if my insurance didn't.

So, I'm going to do whatever I need to do not to pay it. I don't pay over $330 per month to be shafted.

[Kori Ellis]

First like stated above fax your insurance carrier your medical bill with 45$ co-pay on it. And the letter saying if your not approved you pay in full upfront as thats some kind of proof although weak that they approved the test. Since you paid the 45$ if you don't have that reciept get a bank statement or credit card statement showing the payment.

Sorry, read the original post. I didn't pay the $45 .. it wasn't a co-pay, it was the balance and they billed it to my secondary insurance.

[2Blonde]

I agree. You shouldn't have to pay a dime. Usually if you keep calling them enough and are firm but nice and they see that you aren't going to let it lie then they come around. It also helps when they know you are intelligent enough not to take their usual BS garbage that they throw at the general public. The case manager thing has always worked for me because then I get one person who I can talk to multiple times and build a relationship with and it helps because then they will go to bat for me with their superiors. Just a thought. Good luck.
I hope you get some answers and cures soon.

[Kori Ellis]

The case manager thing has always worked for me because then I get one person who I can talk to multiple times and build a relationship with and it helps because then they will go to bat for me with their superiors. Just a thought.

Thanks I'll call them on Monday (or Tuesday if they are off for MLK).

[Kori Ellis]

No, you aren't an idiot. I figured you were reading the end of the thread moreso than the beginning.

Anyway, I have faith it will work out.
Thanks for everyone's input.

Sequ - I still want to know why you say that Unicare isn't "traditional insurance". :wtf

[JudgeBean2000]

Kori, I really can offer no helpful advice, (got burned by Humana, whom I have no fond feelings for) but all I can say if fight it. For whatever it's worth, we'll be here.

[SequSpur]

Unicare, depending on the plan, can have a WIDE variety of reimbursement procedures.

We never accepted Unicare or tried to contract with them because their approval process and reimbursement process was different than everyone else.

Usually, there is copays, a deductible, a coinsurance and thats it. It's pretty easy to figure out based on percentages, but for some reason Unicare was impossible to collect from or figure out what they were going to pay for. In fact, all of our Unicare claims were paid by the patient and they were asked to collect from their own carrier or sent somewhere else.

[Kori Ellis]

Weird. Mine is a straight forward PPO with generally the same rules as the BC/BS PPO that I had in California. I never have had to handle my own claims.