My HMO won't cover part of my insurance claim. Do I have a valid case?

Question

My regular doctor referred me to a gastroenterologist so that I can get a colonoscopy. I got a letter in the mail from my HMO stating that the referral was going to an external partner due to "a high volume of GI requests". They provided the contact info and I scheduled an appointment and had the procedure done.

I was getting my claim letters one-by-one and everthing seemed to covered, until one day I received a denial of claim for the lab work ($350), which unbeknowest of me, was "not authorized" by my insurance company.

Should I be responsible for this amount? After all, the letter stated that they couldn't provide the service directly themselves, and referred to me the external partner which in their words was "authorized". I followed my HMO's direction to a tee. How was I to know that an "authorized" partner that THEY referred me to would send lab work to an unauthorized lab company. Do I have a strong case for appeal?

Answer 1

If you had the procedure preauthorized then they should of covered the costs. You need to have proof of this to have a case. Call your insurance company and speak to the claims department and explain the issue. Most of the time they will resubmit the claim.

Good Luck.

Answer 2

By saying "not authorized," do you mean that they're saying that the lab company used was not in the network?

If so, then no...you don't have a "strong" case for an appeal.  Ultimately, its your responsibility to make sure that all the providers (lab, x-ray, etc.) are in the network, not the doctors.  (You might not think that's fair, but unfortunately that's the way it is.)  You can still appeal, of course, and I'd encourage you to do so if it will make you feel better.  I just wouldn't say that you have a strong case.

Or is your insurer saying that the lab company is in network, you just didn't have a referral on file to the lab company?  If so, that would be something perhaps relatively easy to fix...as long as the lab company is in your HMO network, then just have your regular doctor put a referral into the system.  (This will not work if the lab company is not in your HMO network, of course.)

I have a feeling that what your saying is the lab company is out of network...I wouldn't hold my breath about getting anything overturned if that's the case.  But certainly appeal with whatever documentation you have.  (Keeping in mind that just stating "I assumed the doctor would use a lab in the HMO network" is not likely to be sufficient...you'll need to come up with some supporting arguments.)

Answer 3

Yes you do.  I had a similar case years ago where my doctor performed surgery at an unapproved surgery center.  I got preapproval and then the pathology, etc. was denied.  I had to fight for a little while until I found somebody that "got it".  It would have been impossible for all of the other services to be performed at a different place.

Answer 4

Call your State Assemblyman or State Senator to ask for their assistance. They usually have attorneys working in their offices.

You have to keep fighting!

Good luck.