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Health insurance question (non-political)

Discussion in 'Anything goes' started by Smallpotatoes, Oct 14, 2009.

  1. Smallpotatoes

    Smallpotatoes Well-Known Member

    When I got home tonight, I went through my mail and found a bill from the company that did the MRI on my knee in May. The bill is for $1,000.
    Of course, by the time I got home it was too late to call either my insurance company or the MRI company.
    I remember a few weeks after the MRI getting a statement from the insurance company about payment being denied for not having the correct code or something like that.
    Is there any chance that I could get the MRI people to resubmit the claim?
    If that doesn't work, would the MRI company be willing to let me pay, say $100 a month?
    I'm supposed to have surgery on my knee in December. In light of this, I'm tempted to cancel it. I can walk and do most of what I have to do during my daily life. I just can't do squats and deadlifts like I did before. I'd like to do them again, but if I'm going to get more surprises like this, it's probably not worth it.
    I guess I know what I'm going to do with the car insurance settlement money now.
  2. Sam Mills 51

    Sam Mills 51 Active Member

    You shouldn't be on the hook for a botched code if that was indeed the case. See if you can talk with someone in billing with the group in question, have it reviewed, properly coded and rebilled to insurance.

    In some cases, the insurance company will listen to reason. Sadly, though, there are times where that's precisely the loophole they need to deny the claim (I'm looking directly at you, Aetna and United Healthcare, for starters). And it's sad because, if you're correct in your description, this isn't on you.

    Call the billing department of the MRI company. Many will offer financing, and some might even allow you to set up a contract pay interest-free depending on the particular place and their willingness to work with customers. The option might also be out there that if their loan arrangement is interest-bearing, ask about the APR. There could be a chance that you'll be better off finding a loan arrangement on your own that offers a better APR ... IF the company with which you're dealing cares more about just getting its money as opposed to trying to control its method of contract pay.

    Hope something here helps. Good luck.
  3. Smallpotatoes

    Smallpotatoes Well-Known Member

    Is it worth still having the knee scoped?
  4. fishwrapper

    fishwrapper Active Member

    I spent a couple years of my life appealing denied claims from insurance companies. (Sick daughter)
    First things first. They won't stick you in the tube (MRI) without insurance authorization. It's too expensive of a test for companies to do without knowledge of payment. So, I'm (almost) certain you're ok there. (There's a chance you might have a $100 or $150 copay on MRIs, but that would have been collected at the time of the service.)
    Next, you need to call both the imaging facility and your insurance company. Have the imaging facility resubmit the procedure. Notify your insurance company of the date of the procedure and the denial date on the letter. (That's important in case of further appeals.) Notify them you're contesting the denial and plan a re-submittal.
    But, this sounds like a clerical error. And, in no way you should be on the hook.
    Good luck.
  5. Smallpotatoes

    Smallpotatoes Well-Known Member

    One problem: I can't find the denial letter.
  6. Smallpotatoes

    Smallpotatoes Well-Known Member

    OK, I talked to my insurance company this morning (after a sleepless night. Once I got to 5 a.m., I realized sleep wasn't in the cards last night).
    They need the MRI company to provide medical records to do a retro review. They said, I needed to have the MRI pre-approved and since I didn't do that, they need to do the retro review.
    They also said I may be on the hook for a penalty of $500 or 50 percent, whichever is less.
    They said all this information is on my insurance card. It isn't. It may be in some paperwork I received when I enrolled, but it's not n my card.
    So it's all my fault, I guess.
    And they'll get that penalty out of me over my dead body.
  7. Sam Mills 51

    Sam Mills 51 Active Member

    By information, they mean phone numbers and mailing addresses. Those should be on your coverage cards. Calling them might have helped, and all the back-end work is what's setting them off.

    But step-by-step instructions on pre-appovals or pre-authorizations? Um ... no company puts those on the card. On that front, they can get over themselves.

    Whether or not the knee should be scoped should be between you and your physician, not the insurance company. Obviously, there will be the issue of medical necessity and assuming you get that, the coverage company should kick in per your parameters (possible co-pay, deductible, co-insurance and out-of-pocket maximums).
  8. mustangj17

    mustangj17 Active Member

    I think health-related bills are always interest free. At least that was the case with my surgeries.
  9. Ace

    Ace Well-Known Member

    sp and anyone else.

    ALWAYS call the insurance company and doublecheck whether an expensive elective procedure like an MRI is approved or not.

    You CANNOT rely on the doctor to know whether your insurance will pay or not. They deal with hundreds of patients with dozens of types of insurance. They are not going to know the details of your policy.

    Hell, they can't even tell me what my insurance company will pay for an office visit.

    Even is something is pre-authorized doen't mean that the insurance will pay in full if they had a limit on how much they think something should cost.

    But the insurance refusing to pay the doc or the lab isn't the end, it is just the start.

    I'd keep fighting till they paid it.
  10. Bob Cook

    Bob Cook Active Member

    Pretty much every imaging procedure now requires a preapproval. Your doctor may not know it, or may count on you to do it. That's why they have signs up saying the patient is responsible for knowing what insurance will cover. Not that you ever know, either.
  11. EStreetJoe

    EStreetJoe Well-Known Member

    Here's one that baffles me and I won't get the joy of having this benefit much longer.
    My former employer (whom I'm still receiving benefits from) has us using BCBS of Delaware, despite the fact that we're in NJ (guess the corporate offices of the parent company are in Delaware or something).
    BCBS just starting requiring pre-authorizations for MRIs this year. However since I've got BCBS of Delaware, they only require a pre-authorization if you're using a Delaware provider. If you're using a provider in another state, you don't need pre-authorization.
  12. spnited

    spnited Active Member


    A. You MUST find out before any procedure what your insurance company's policy is ... pre-approval, pre-review, etc.
    B. You MUST make sure the people doing the MRI are clear on what your insurance covers before youi go into the tube.
    C. If you get a claim denial letter, call both the facility and the insurance provider IMMEDIATELY to find out why there is a problem. And keep the damn letter in a safe place so when it becomes an on-going problem you can refer back to where the trouble began.
    D. As Ace, this is far from over. You now have to keep on both the isurance provider and the lab to get this straightened out.

    The problem is our health care system is far too complex -- different rules for different insurance companies; need referral, don't need referral; pre-authorized or not ... etc.

    You have to protect yourself from square one.
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