A blast from the recent past comes back to bite me in the butt! Cautionary tale!

[MDemisay]

Good afternoon fellow frustrated AN ers,


Just as I was comfortable waiting out my after effects from the GK procedure I had done on June 11, NOW I find out that I wasn't precertified to have the CT scan I had done immediately preceding the procedure as a way of targeting the tumor (Irv)? How could this be??? My doctor's secretary had completed all the necessary paper work.  My wife just called my health insurance company.

My question is have any of you gone through this? Dotting the i"s and crossing the t's is something I'm very good at, being a bit of a bureaucrat myself. I even went so far as to have my bloodwork faxed 4 times and didn't leave the hospital even when the doctor's office secretary's fax machine wasn't working. Does anybody think I would purposefully defy the bleeding preapproval system when I know full well I would be denied otherwise?

Talk about bureaucratic screwups? This has to be the one that takes the cake!

4 months later I find out about this!

My wife just texted me that Oxford said that they NYPresbyterian did not get precertified. But because they are in the network they (Oxford)can't bill us for it. they are (NY Presybetrian) are responsible for it and they would have to file their own appeal. Translation: NOT our problem!

Make ..... sure you get all of your preapprovals people!

Even big hospitals make mistakes sometimes, just a cautionary tale! I'm sure it isn't over yet.....They'll find someway to make the patient responsible!

Mike

[leapyrtwins]

Mike -

I'm sorry you're having to deal with this and I hope it works out for you.

I've never run into this situation.  I'm the type who calls my insurance company to see if I have to pre-certify anything more than an office visit.  I've called for things like colonoscopies, mammograms, endoscopies, etc., and have been told that it wasn't necessary to pre-certify "routine" things.  But I never know what is considered routine - and I don't want to wade through pages and pages of my policy to find out. 

My neurotologist's office generally calls to pre-certify my post AN surgery MRIs, but I know that ultimately it's the patient's responsibility (something every insurance company I ever had a policy through loves to tell insureds).

I live by the "better safe than sorry rule".  I'd rather bother my insurance company unnecessarily than potentially be penalized monetary. 

Guess my best advice to people would be CYA (cover your *ss) and when in doubt, call.

Jan     

[Kathleen_Mc]

I am SOOOO glad here in Ontario we don't have to do such things, I'm sure it just adds a great deal to the stress of being ill. I am sorry you guys have to go through all this crap on top of what is already a horrible time in your lives.
Kathleen

[Suu]

Hi Mike
Over here (in Aus) we have a problem of not knowing the 'gap' between what our health insurance will pay and what a doctor or hospital will cover.  Sometimes we can be surprised by a bill for a few dollars to thousands!
It's a little known thing that if we ask for our doctors and any treating professional to "participate in the gap scheme" then we don't have a problem but who remembers to ask when we're all just wanting treatment?

I sympathise with you for sure.

It's called passing the buck over here.

Stay strong our dear friend.

Suu xx

[Jim Scott]

Mike ~

Let me add my note of sympathy for this unexpected hassle.  Thank goodness the hospital is liable for not obtaining pre-certification.  Frankly, the hospital made the error (not getting the procedure precertified by your insurer) and it is only reasonable that they have to deal with it.  Unfortunately, it doesn't always work out this way.  I don't expect the soon-to-be-fully-implemented Patient Protection and Affordable Care Act (PPACA) to be much of an improvement - but that's a separate issue. 

Thanks for the pertinent warning regarding obtaining procedure certification from your insurer.

Jim   

[millie]

Mike-Thank God it is the hospital's problem!
I myself transition to Medicare October 1.  My 65th birthday is October 17th, the day of my surgery.  I have called Medicare and the other New York plan (which will become secondary) but after reading your words, I am calling everyone again on Monday to make sure all will be covered.  I was told by the doctors' offices that they took Medicare.  However I will recheck.
Thanks for the heads up-Millie

[MDemisay]

Thanks everyone,

With this "system" we have, I would have figured that cost shifting would have figured into the game somewhere or other! However, The doctors office made me feel so comfortable going in they had it all taken care of I thought. Goes to show you what insurance companies will do to avoid covering you. This doesn't speak well of them does it?

Oh well, just par for the course!

Millie and others who are just entering into this, I double checked with everybody that they got all necessary pre certifications  done. I didn't triple check!

Act accordingly!

I trust in God that everything will shake out in the wash! I dotted all the I's and crossed all the t's, I made sure of that!

Mike

[Denise S]

Oh YES, I have ran into this with MRIs twice.  Most recent was my 2nd annual post op MRI a year ago.  Supposedly the dr office got it preregistered, like normal.  But then the insurance had it broken down into 2 portions (the more thorough IAC was separate).  So they wouldn't pay for that 1/2 my MRI $3,800!!   "I" ended up having to make all the calls, and back & forth b.s.!!  Dr office said 'it should ALL be just one procedure, the Hospital messed up on what the did & how they charged!  Grrr, hospital claimed NO.  So I just argued, hey I got the papers for an MRI , same as in the past and you have a precept info.....it is NOT  MY fault!!! 
They continued to try to send me a bill & called manager again and said I am MOT paying for someone else's screw up.....you have an issue, YOU make the calls to the dr & insurance.....I shouldn't have to do that too!!!   My next mo that bill was actually a 'write off' of that amount!!!  10 months later!

The time before was an $11,000 MRI for full spinal due to the multiple issues I have in there.  I got bill and they said cause it wasn't preapproved.  Luckily my that doctors office fessed up and admitted it was their mistake AND also said hospital should have checked, so the Whole thing was written off!

Me & insurance have a HUGE love, hate relationship!!!

Denise