Ever had your medical care tuned down by the Insurance Company?

Question

I recently had surgery and turned in the medical paperwork to my insurance company. They paid part of the work but turned down others. It was all precertified but not according to the insurance people. They say they will not pay and I am struggling to get answers.

I suspect a good percentage of insurance claims are turned down because most people do not have the understanding to figure out how to fight the insurance company rules and buracracy. How about you. Any insurance horror stories?

Answer 1

If the surgery was precertified, I can't understand why they are refusing to pay.  Are they saying certain services were not cleared with them when they should have been?

An HR person where you work might be able to help you understand what is going on.  They also have direct lines to the insurance providers.  Just be careful what you say to HR, because they work for company management and not for you.  

I think you're right about people not having the ability to deal with insurance companies, and I think this is deliberate on the part of the companies.  They want to do what they want to do whenever they want to, and any attempt to even understand what they've done in any particular instance is met with resistance.  I worked in medical offices for over 20 years of my life, and I still have communication problems with insurance companies.  

One of the issues with the companies is that they have outsourced their "customer care" lines, like so many other companies.  When you call these lines you get some little girl in a trailer in Nebraska.  She neither knows nor cares, and she doesn't get paid any more if she helps you than if she ticks you off.  

I think HR is your best bet.

Answer 2

Insurance companies do not cover everything. You should have prequalified your surgery. You can also sometimes get discounts using doctors or hospitals that are hooked up with your insurance company.

I know it's totally confusing, 10 years ago my husband and I both had cancer, out insurance was suppose to be $2k out of pocket expenses, that problem was the insurance company only allowed so much money for procedures, meds,ect.

So the difference in what we where charged and what they would pay ended being several thousand dollars!!

Talk to your insurance company about what they cover and if you can get better rates at certain doctors.   Luck  E

Answer 3

Yes, I've had medical care turned down.  Some I've appealed and had it straightened out, some not.

My insurance is with Cigna.  It's a great plan, but they are SO fast to deny.  

My most recent horror story is the birth of my last child - the C-section was covered, but Cigna is denying coverage for the guy that sewed me up afterwards.  Guess we should have used band-aids.

I've had claims denied for "no coverage in place" (DH has worked at a fortune 100 company for 15 years with no gap in insurance coverage), "no pre-authorization" (we go it, I have the numbers), "not a medical procedure" (for the other baby's tongue tie, when he couldn't EAT as a newborn), along with claims denied just because the prior claim, incorrectly denied, was denied.  

I spend a LOT of time fighting with Cigna to get our family's claims covered.  The scarey thing is, I know how the system works.  People who do NOT pay attention to those EOB statements in the mail, and who do NOT spend the hours getting through, writing letters, appealing denials - well, they're getting screwed out of benefits rightly theirs.

Answer 4

First, check your policy for the appeals process. Any correspondance you have with them is best done in writing (and if you are requesting an appeal-A MUST!) You say it was all pre-certified (but not according to the insurance people). Did you recieve a copy of the pre-certification? If not, it will be difficult to prove that it was pre-certified. What was pre-certified? Are the services they are denying outside the scope of the pre-certification? If so, and they were medically necessary, you may have to ask your doctor to write a letter stating the medical necessity for those services. If the services were provided by a out of network provider and you had no control over that choice, you may have to get the provider to go to bat for you on that.

If you do not fight it, you cannot hope to win!

Answer 5

Tried it on me.  Yes precertified but ins. co said my hosp stay should have been 2 days not the 3 I needed.  Thankfully the Doctor and Hosp. fought the ins. co.  Doctor said the extra day was necessary because I was not responding to treatment.  Go see the billing dept of the hosp. talk to them and see how help they can give you