Insurance co. won't finish payment

[jb]

Hi all, I'm having a hard time getting my insurance company to finish paying for my treatment and I'm not quite sure what to do.  I had an out-of-state claim, but apparently it was misprocessed as an out-of-network claim and only paid at 50%, even though my procedure was pre-approved at 100%.  The insurance reps I've spoken to on the phone (multiple times) have all agreed it's a mistake on their end, and assure me that my claim is 'prioritized' for reprocessing.  This has been going on for 3 months and nothing is getting done.  In the meantime, I'm left having to pay $1,500/month to the hospital on my remaining balance due.  I expect to be reimbursed eventually, but am beginning to wonder?? 

I'm about ready to call the local TV 'action guy', but I was just wondering if anyone had a similar experience and how they resolved it.  Are there any insurance 'watchdogs' I can complain to?

[OMG16]

JB I'm sorry to hear that you are having problems.  Is the hospital helping you with this?  If not call the insurance back and request to talk to a supervisor.  When you have them on the line get the name of the person you are talking to and their phone number and extension.  Ask them to give you their fax Number and fax a copy of the letter along with an appeal letter.  You only have a short period of time to do this so sending an appeal letter now is a good idea and can prevent problems down the road.  Ask them when they plan on making the additional payment and remind them nicely that it was a clean claim and everything was pre approved and that it should have been processed 30 days from the date they received it.  Since it has been so long and is costing you money that you do not have ask them nicely to process it now.  Then ask when you should expect payment to go out.  Let the hospital know all you are doing and ask if they can suspend the requirement that you have to pay the balance until it is all settled.  If that does not work call the news and give it over to them.  I have seen in our area this has been effective.  Good luck it is a nightmare.  16

[sgerrard]

I would get a phone number and fax number for the hospital, and the same for the insurance company. Be sure to contact the doctors involved with your procedure directly, so they know what is happening. They will refer you to their assistants, who should be able to help organize things. Get the assitants' phone numbers and fax numbers. At the insurance company, try to get in touch with the nurse practitioner or some one who can make decisions directly. Then get these two groups talking and faxing directly to each other.

Ask for copies of all medical reports, etc. from the hospital, and make sure the insurance company has all of them. Then fax them another full set just for good measure. Get copies of all billing records you have so far - and fax everyone extra copies of those as well. If someone says it will be reprocessed, be sure to write down their name and their statement - and fax it. If you paid something to the hospital, make copies of those statements and payments, and a note that you expect reimbursement. Fax everyone copies of those as well.

Your case needs to land in the in box on both ends every day until it is cleared up, with all pertinent information readily at hand, no setting it aside while they look things up. I found that having copies of everything, and faxing them to both ends, and getting people talking to each other, made all the difference in getting the billing process straightened out and working smoothly. Call both ends, and fax everything again if they are not already holding it in their hands as you speak. Communication is key.

Hope it happens soon. Steve

[Don]

 Dealing with these people is always a drama as I mentioned I am blessed as the choices I made early in life left me with 4 health care options for the rest of my days I am presently covered by a Federal Blue Cross plan, Military Tri Care and the VA and Medicare A&B and they still try to bill me? I had to go back to using the VA once I got my SSDI and Medicare as Medicare becomes your primary and they refuse or are unable to coordinate benefits and dont pay for most things? Anybody who thinks government health care is the answer stand by its all done with smoke and mirrors, my premiums are paid by my annuities and retirements but the system leaves a lot to be desired I paid out of pocket for my tumor removal not knowing my Blue cross was still valid as I was not yet on SSDI/ Medicare and it took about 3 months to get my money back I came home on a Thursday, the bill showed up Friday they had their check on Monday but me I gotta wait 3 months? Be firm go to the TV action line as healthy folks have no idea of the scams I used to respect the medical professions till I died and now know better be fair but firm never give an inch your life depends on it. I may be brain damaged but Im not stupid.............

[jb]

Thanks for the advice.  You guys are right, I'm just going to have to dig in with these people and get things in writing until this gets settled.  I thought the hard part would be getting the insurance co. to acknowledge their mistake.  Still hard for me to believe they admit the mistake (at least on the phone), but don't do anything about it for over 3 months. 

The hospital billing people have actually been pretty nice, but reminded me it's ultimately my responsibility, so I went ahead and started paying on it.  They said I'd get reimbursed when they get the insurance money, so hopefully it'll turn out that way.  We'll see....

[lori67]

jb -

As long as you make a monthly payment to the hospital - any amount - even $1 - they can't turn your account over to collections or report anything negative to the credit bureaus.    The also can't charge interest.  If I were you, I'd send them $20 to keep them happy and let them know you intend to pay, but I'd keep that $1500 in my pocket!

I had a $1000 copay for my surgery because my doctor is out of network - I could have paid it off, but they get their $20 a month and I am free to use the rest for other things - like credit card bills or something where the interest would rack up if I didn't pay it off.

This may be different in some states, but in the 4 states I've lived in, that was how it was.

When you talked to the insurance company, did you talk to a supervisor?  I always insist to speak to a supervisor and then make sure I get their full name and extension.  That way they know if things don't get cleared up, I have their name as the person who was supposed to be accountable.

Good luck.  As if none of us had been through enough already - we have to fight with the insurance companies too!

Lori

[mema]

Jb,


I know for myself and my husbands medical bills, sometimes we had to go back to the medical facility in person to get better results and correction.  I know it was an out of town bill, but if it isn't too far it might make a difference to go in person. 




mema

[jb]

Thanks for all the advice.  I think it is f-i-n-a-l-l-y getting worked out.  My problem was strictly with the insurance company.... I have a high-deductible policy with a max out-of-pocket of $5,000, but they completely ignored that and charged me over $26,000.   $26,000 was remaining after they had already adjusted and paid at 50%!   Anyway, I think I finally got through to the right person today (after 4 transfers).  She had to put me on hold to talk to her supervisors for 30 minutes, but seems to finally understand the issue and has worked back through all the claims that need full and partial reprocessing.  She told me to expect something in 7-10 days and I did get her name and department so I can call back if necessary.  I feel like things are at least heading in the right direction now. 

[sgerrard]

jb:

That is good news. No one suggested that the process is neat and tidy and quick, so delays and reprocessing and so on are to be expected. But, if they have acknowledged the problem, it seems to me they will end up making all the adjustments. You may still get dinged for a bit more than you expected, but at least you should end up back at 4 figures, not 5. Stick with it!

Steve

[leapyrtwins]

jb -

that's great news!  I'm glad everything is working out.

In my experience, you really have to stay on top of insurance companies.  Mine just paid my doctor's bill from my BAHA surgery, but they did it wrong.  They processed the claim as if the doc was out of my network and showed that I was responsible for approximately $1,300.  It was an error on their part, since he is in my network and in fact, I owe nothing.  They tell me it will take a week to straighten out and adjust the claim, but if I hadn't questioned them the doctor's office would be expecting me to pay.

Jan

[jb]

Thanks, Jan.  This is my first real medical adventure so I'm still learning the ropes.  Still doesn't seem like it could be that complicated.  Good luck with your BAHA!  -JB

[leapyrtwins]

jb -

you are so lucky that this is your first medical adventure!  I'll bet no one's ever said that about your AN before 

Actually this is my second medical adventure - the first one involved 8+ years of infertility treatments and lots of fighting with my insurance company.  Thankfully in the end, they covered much more than I thought they would and the result was 2 very beautiful children for me 

Let's hope that both you and I are at the end of our medical adventures.

Another jb (Jan B)

[Jim Scott]

Hi, jb:

Your insurance hassles are all-too common.  My wife - a former insurance company claims supervisor (auto & home, not medical)- knows the ropes so she deals with the insurance company.  I just have to identify myself to the insurance rep and give verbal permission for my wife to speak for me in some instances.  She is patient and intrepid.  She also keeps very precise records of who she speaks to, their extension and what they said.  Recently, we had a discrepancy in that the insurance provider (Blue Cross) was only paying 80% of the claim when I had already met my annual deductible (for 2007) and they should have been paying at 90%.  That 10% can add up, especially with a $3,000. MRI bill.  After many calls and much time, the issue was resolved in our favor.  I did nothing and give my wife full credit for that 'win'.  The sad fact is that insurance companies make mistakes and also try to view claims in a way that favors them not paying or paying as little as possible.  Also, doctor's offices and hospital billing staffs sometime mess up, too, which complicates things. 

As for paying hospital bills: following my surgery and subsequent radiation treatment (FSR) I owed quite a bit in co-pays even after my insurance paid out a total of near $100,000. for my numerous MRI scans, complicated pre-op tests, doctor's fees ($28,000.) and hospital charges of well over $50,000.   I contacted the hospital, anesthesiologist's office and MRI center and made individual arraignments to pay them each a monthly payment that I could afford.  They usually said "O.K." without hesitation.  The hospital wanted me to pay off my bill within 12 months, which I was able to do without a financial strain, so I agreed.  Had I not been able to pay the entire bill in 12 months, I would have told them so and simply paid as much as I could every month.  I doubt I would have had a problem as hospitals get stiffed all the time by indigent patients and those who simply refuse to pay unless sued, so my honest offer to pay a monthly stipend would have been reasonable.   

I suggest you or anyone faced with high medical bills ask the doctor or institution to allow you to pay the bill incrementally.  Most will and as long as you're making a 'good faith' effort to pay the bill with a regular monthly payment, even if it's small, you should be protected by law from collection actions on the part of the doctor, hospital, etc.    Even now, when I receive a medical bill too big to pay at once, I simply send as much as I can and pay it off in quarters, thirds or by half as the situation presents itself.  I've yet to receive a complaint from any medical office or hospital about doing that.  They just keep sending a new bill each month reflecting my payment, without comment.   The key is to, first, ascertain what you actually owe, after your insurance has paid it's full obligation (which can be a lengthy process, as you now know), then to attempt to make a verbal arraignment with the doctor's office, hospital or other facility to pay a monthly payment that you can afford.  If they demand more than you can afford, simply state the truth: that you can't pay what they demand but that you will pay whatever it is that you can afford and make it clear that you fully intend to settle this bill, although it may take awhile.  That is acting in good faith and most doctors, hospitals, etc will go along with you on that basis.  Of course, in some cases, you can attempt to borrow the money needed to pay off the bill from relatives, friends or through a personal bank loan, as some folks do.  Then you just have to pay back the lender, as with any other loan.  However, in my experience, hospitals don't charge interest on your debt to them from an unpaid bill so it can be cheaper to pay the hospital directly each month, depending on your situation and resources.

You seem to be making progress with your claims so at this point I'll just wish you continued success. 

Jim

[jb]

Jan, that's a great story about your children!  I guess perseverance does pay off!! 

Jim, thanks for your sharing your experience.  I have been amazed at how quickly my bills added up with this crazy thing.  I think my story is nearing a happy ending though.  The very nice woman I spoke with at the insurance co. a few days ago called me yesterday and went over exactly which claims they have now paid in full.  Basically, all the big stuff I've been paying on!!   She said the hospital will be receiving payment within 7 days.  I just hope the hospital remembers they have to reimburse me now!!! 

[sgerrard]

The very nice woman I spoke with at the insurance co. a few days ago called me yesterday and went over exactly which claims they have now paid in full.  Basically, all the big stuff I've been paying on!!   I just hope the hospital remembers they have to reimburse me now!!!

Excellent! Do we get a commission? 

Steve