Can insurance companies take money back for a procedure they already pre authorized and make the patient pay?!

Question

The procedure was approved by the same insurance company for another lady under the same plan and the same doctor. The normal steps were taken. A doctor's visit to diagnose, the request for approval was sent to the insurance company, and it was approved. It was at least several months before the procedure actually took place. Then here recently (4 months after the procedure) we get a bill from the doctors office saying we owed 5000 for this procedure that had been authorized already by the insurance company.... Even though the procedure was needed for my wife's health we would not have not gone through with it because we did not have an 5000 in the bank. During a checkup visit yesterday the doctors office explained that the insurance company had requested that the money for the procedure be returned within 10 days!?!? so they returned it. Now we are suppose to pay the 5000!?!? Shouldn't the Doctor or insurance company be at fault? What can we do? What is be the best course of action?

Answer 1

Yes, it is possible.  But there needs to be a specific reason.

When a pre-authorization is given, it is still dependent on the patient's benefits being in effect on the date the services were actually performed.

If there was a change in circumstances that didn't get reported to the insurance company, they do have the right to request the money back.

Examples of reasons why this could occur:

- Change in coordination of benefits info (in other words, the insurer discovered that another insurance company should have primary liability for the bill)

-Change in the benefits on your policy (for example, if your employer changed your policy and the service which had prior auth is now excluded from coverage)

- Cancellation of your policy (for example, if someone stopped paying the premium for the coverage.  Or, if the insurance company made your policy invalid, due to discovering that you lied on your insurance application.  Things like that.)

What you need to do is find out *exactly* why the money is being requested back.  Then you will know how to proceed and if it is a legitimate takeback.

If you want to update your question once you figure out the reason for the takeback, someone here might be able to advise you on how to proceed further.

Answer 2

First off i never heard of this before, returning money back to an insurance company, after a procedure was done. Something don't sound right. I would call your insurance company and let them tell you the reason. Even if your stuck with the bill they can't demand it in full. You make a payment plan all doctors and hospitals do that.

Answer 3

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Answer 4

Your issue is with the insurance company.  Communicate with them.

Answer 5

Did you call your insurance company?  They are the people you should be talking to.  They are the only ones who can help you.  If the first person you talk to is not helpful, ask for a manager.  Keep calling until you get someone who can help.

Ask the doctor's office for the pre-approval paperwork they received if you don't have a copy.  If you can't work it out with the insurance company, get a lawyer.

You can also try your state's insurance commissioner for assistance.

Answer 6

Yes the insurance company can ask for it back.  The doctor is still entitled to payment for services rendered.

What you need to do, is appeal the denial of coverage.  If you disagree that it shouldn't have been declined, you need to tell them WHY they should have covered it.  And as a hint, "you paid for it for HER" is not going to cut it.