Is it possible my insurance company will reconsider my claim?

Question

ok,I had emergency surgery and my physician was in network covered. A week after surgery I get a letter stating the hospital that she practices out of is not covered but I did follow protocol by notifying them 24 hrs prior . Now I am being billed a couple grand. I am planning on appealing and wondering if anyone has insight on whether I have a prayer in h**l. Any suggestions will be appreciated. Thank you.

Answer 1

You always have a prayer in h**l.  Insurance companies often negotiate bills.  What you have going for you is the fact that your surgery was "emergency surgery" and therefore can often evoke an exception to the notification rules.  I would suggest you review your policy carefully and see what it says about notification and preauthorization.   If your physician is in your covered network and practiced at the hospital where you had your emergency surgery, I'd say you have a good case.   Having a physician covered but not the hospital could be considered  a kind of bait and switch tactic used by the hospitals to steal money from insured people. Insurance companies also like to use tactics like this because they want to make money.  

I believe all insurance companies and hospitals and doctors and medical facilities should be NOT FOR PROFIT organizations by law.  The reason is that patients have no control over costs and are required to sign a blank check to the hospital and doctors thereby bankrupting people who have a serious illness.  Additionally, as the hospitals increasingly go to being for profit, the costs associated with getting insurance and medical care rise astronomically and again, because people don't have control of those costs, it results in a kind of tax on the people.  I would like to lobby Congress on the issue of "for profit medical care"  -- against it. And against universal health care.    I would suggest you negotiate with your insurance company and then make sure you bring this to the attention of your state and federal Congress.  Again, emergency generally evokes an exception.

You might also place insurance notification responsibility on the hospital because they take copies of your insurance cards and they do understand how benefits are paid.  When you sign the admission forms, you are required to give them a kind of carte blanche and it could be reasonably argued that since they bill the insurance company directly, they have knowledge of the policy requirements (most policy requirements) and therefore take on the notification responsibility by proxy.

Answer 2

You have a problem  While the physician is in network, the hospital is NOT.  As the policy holder, it's your responsibility to ascertain that ALL service providers are within your network.  Your insurer may pay SOME of the claim, but it will certainly be at a reduced amount over that which the network hospital would have been covered.

Answer 3

Fight it. Read your insurance contract's fine print and understand the arbitration section. Follow the procedure and open a dispute. If all else fails, send the bill back to them and ask them for a review. Keep sending it back month after month and you'll see 'correction' after 'correction' lowering the amount due every time. If you keep doing this while the dispute is open, then someone will be watching and taking action. Don't let the insurance companies get you down. If you followed the rules, and they didn't, then you have no obligation to pay what THEY are supposed to be covering. You're paying them for their services, they need to own up to their end of the deal.