Insurance nightmares!

[MDemisay]

Dear Jan and others who may be concerned about this post being appropriate,

I should just warn you I am very excited and frustrated and emotional right now! Just when I was feeling good about my GK treatment procedure (that occurred on June 11), just when I thought I was through with the roller coaster of mixed feelings of should I go through this, a letter from my insurance company arrives stating that because I didn't seek preapproval from them that my insurance company wouldn't cover the payment!

First of all, what can I do now a full 4 months after the treatment? Secondly the hospital and the doctor's office were all well aware of this procedure. If the insurance company has an issue with it shouldn't they go after the hospital first? I'm very frustrated that even with the coverage that they would attempt to get us involved!

In a conversation had with Oxford they said that NY Presbyterian was responsible because they did not get a precertification. The hospital is in the network and they can't bill us for it!The hospital is responsible and the hospital would have to file their own appeal.

I'm somewhat gratified that it after all that is not our problem!

All is not rosey with the system we have!

What is most frustrating is the fact that the insurance companies are still up to their old tricks of trying to pass the cost on!

Have any of you experienced this?

Mike

[leapyrtwins]

Dear Jan and others who may be concerned about this post being appropriate,

If I'm the Jan you're referring to, I have no say about what is appropriate or inappropriate on the Forum.  I'm not an ANA staffer, nor am I a Forum moderator.

Just for the record though, I have no issue with this post.

Carry on 

Jan

[skipg]

Mike I do know from my experience that the dollar seems to ultimately drive the system. The insurance companies have many hoops to jump through and I never did like to play basketball. My most recent MRI was approved with an authorization number. I get a frantic call from member services wanting to know why I had my test done at the wrong facility. It seems someone authorized the MRI to be done at UVA, a 3 hour drive from here. I was told that ultimately it is my responsibility to make sure everything is in order but they are going to backtrack and find out who made the mistake and authorized UVA when in fact I was sent to a facility 5 min from my house. I have not heard back yet and assume they corrected this. The irritating part of this is that "ultimately we are responsible for ensuring everything is correct". Go figure. I could go on about physical therapy not being covered after receiving a letter of approval, which I kept, and other mishaps. I believe the system needs some tweaking but do not know if a complete overhaul is necessary.
Skip

[MDemisay]

Skip,

Understanding cost avoidance is partly like basketball! Partly like the recent bad calls in the NFL!! I like basketball so I will explain it in basketball terms. Thank you for comparing it. The game (operation) is over, my side has scored a win! They, the insurance company trying to have the game called because of a technicality. I thought that they were on my side, as it turns out that they are on their own side. A cautionary tale for everybody except those that totally pay for their own care.

The participants, the hospital's staff were responsible for securing that payment conditions were met at "game time" (operation time)! I was under the impression that they were! It could be said that the hospital failed to do their due diligence, that is make the patient aware before they performed the CT targeting procedure. It is merely annoying that they did not and that now I find out about it! What continues to infuriate me is that the hospital didn't bring this to my attention at the time  but simply let the insurance company try to come between the patient and the payment for his care.

I know of a technical glitch that occurred at the last minute however! The hospital's staff were under the impression that I was to have an MRI (I cannot because the clips in my head are magnetic) as evidenced by the fact that the very weekend before the treating nurse called me to say that I was going to have an MRI, shocked and amazed by this technical mistake, I informed them that I could not, needless to say, they did a lot of scrambling changing one procedure to another (MRI to CT)and caused me a great deal of aggravation . Interupting a lot of meditation on my part, at the time, I remember being totally flumoxed by the nurse who said she would call me right back! She did and the procedure went flawlessly on that  Monday June 11.

It is truly possible that because I received a CT scan instead, that the proper paperwork for the procedure hadn't been completed.  They neglected to inform me and simply went forward as had been previously planned. Regardless, I received the proper CT targeting test and the procedure went as planned. Irv is dead!

Can I help it if because of the hospitals not filing the proper paperwork (which for all intents and purposes, I was under the impression that they had) that the patient be billed for the error? How in God's green earth is that fair?

I rose from the Gamma Knife table victorious! How can "the game" be called now? Quite a gambit for the hospital to play, wouldn't you say? Who should pay?

Textbook cost avoidance!

Mike