$#@%! Insurance Companies

[mary_bobo]

Chovy,
I work in health insurance…for a major hospital. I know how frustrating that can be. Does your insurance have a contract with that hopsital or doctor. If so, it is the doctor and facilities job to obtain the authorization from the insurance company. Here is what I suggest:

1. Find out from the doctor’s office if they received any form of approval from your insurance company for the procedure. This should have been done by the doctor’s staff.
2. If they did, ask for a copy of the referral or pre-certification and contact the hospital with that information.
3. If they did not, ask for their help. It is their job.

You are right about the insurance companies. Before I converted to the RCC, I had a bi-tubal ligation and it will cost me close to $7,000 to have it reversed but the insurance covered all of my sisters fertilization treatment (we work for the same hospital). The insurance won’t pay for a reversal for me. It is very frustrating.

If you would like me to help you and intervene with the insurance company or need more specific details, just email me!!

Pax

Pax, maybe you can clear something up for me. Is it not the company (if ins. is from workplace) who decides which procedures are covered and which are not? In other words, the company determines what the policy will cover. Additionally, the folks at the insurance company on the other end of the phone are more likely than not to be clerks (not meant disparagingly) who are only parroting what the flip cards in front of them say. It is always good to speak to a supervisor, one who knows a little something about medicine like a nurse. Even then they are there to make money for the ins. company.

Classic example: my husband had to have an upper and lower GI due to bleeding somewhere in his digestive system. He had severe anemia. These procedures were done at the same time. Insurance company did not want to pay for one because “they did not do it that way”. I got a supervisor on the phone and asked him he in wanted husband to have two separate procedures, with two anesthesiologists, two gastroenterologists, O.R. setup times two and on and on. By the time we finished, they paid the bill, but would not have if I had only been willing to stop with the clerk who answered the phone.

Point is, don’t give up.

 

[Norseman82]

Additionally, the folks at the insurance company on the other end of the phone are more likely than not to be clerks (not meant disparagingly) who are only parroting what the flip cards in front of them say. It is always good to speak to a supervisor, one who knows a little something about medicine like a nurse. Even then they are there to make money for the ins. company.

Some insurance companies have hotlines staffed with nurses/medical personnel that sometimes advise people on what to do. If you can get their backing, it might make pre-approval easier.

Also, if there is an emergency situation, the normal pre-approval should be waived, you just need to inform them within something like 48 hours (at least when it comes to dealing with in-network vs. out-of network).

 

[JMJDevotee]

Pax, maybe you can clear something up for me. Is it not the company (if ins. is from workplace) who decides which procedures are covered and which are not? In other words, the company determines what the policy will cover. Additionally, the folks at the insurance company on the other end of the phone are more likely than not to be clerks (not meant disparagingly) who are only parroting what the flip cards in front of them say. It is always good to speak to a supervisor, one who knows a little something about medicine like a nurse. Even then they are there to make money for the ins. company.

Classic example: my husband had to have an upper and lower GI due to bleeding somewhere in his digestive system. He had severe anemia. These procedures were done at the same time. Insurance company did not want to pay for one because “they did not do it that way”. I got a supervisor on the phone and asked him he in wanted husband to have two separate procedures, with two anesthesiologists, two gastroenterologists, O.R. setup times two and on and on. By the time we finished, they paid the bill, but would not have if I had only been willing to stop with the clerk who answered the phone.

Point is, don’t give up.

Yes, employers can limit what they want covered but I have found most cover basic healthcare and any medically necessary services. It sounds to me (I was a nurse before I got into insurance) that in your DH case and the OP case, that it was medically necessary.

The biggest things patients have going for them is knowledge. And getting your MD office to help is good too…most large hospitals (John Hopkins, Duke, Mayo clinic) sign contracts with insurance carriers to receive reduced payments in fees.

Pax (which is not my name but “peace” in latin )

 

[JMJDevotee]

I am glad to hear you are doing well. Take it easy and heal.

Pax