Health insurance question (non-political)

[Smallpotatoes]

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.

 

[Sam Mills 51]

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.

 

[Smallpotatoes]

Is it worth still having the knee scoped?

 

[fishwrapper]

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.

 

[Smallpotatoes]

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

 

[Smallpotatoes]

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.

 

[Sam Mills 51]

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).

 

[mustangj17]

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.

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

 

[Ace]

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.

 

[Bob Cook]

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.

 

[EStreetJoe]

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.

 

[spnited]

SmallPo:

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.

 

[Ace]

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.

Some of the crazy insurance rules vary because of state laws.

 

[fishwrapper]

I just can't see an imaging facility administering an MRI without insurance verification and authorization.
This is a failure on many levels.
1-PCP needed to submit for pre-approval.
2-Patient then receives authorization.
3-Diagnostic imaging center verifies the authorization.
This is awful.

 

[Ace]

I just can't see an imaging facility administering an MRI without insurance verification and authorization.
This is a failure on many levels.
1-PCP needed to submit for pre-approval.
2-Patient then receives authorization.
3-Diagnostic imaging center verifies the authorization.
This is awful.

Bottom line is doctors don't have the time or temperment or inclination to deal with insurance issues. That's not what they went to medical school for.

So the people in the office that do that kind of work make about $8 an hour and are busy with all the crazy insurance information that is written at a grad school level.

You've got to look out for yourself.

 

[EStreetJoe]

Just remembered that about 12-15 years ago I had an MRI denied because at the time I was in an HMO and the PCP (or specialist) put the wrong facility code on the referral. So although everything was according to procedure, the referral was to have the MRI done someplace else and the HMO refused to pay until I went to the doctor's office, go a corrected referral form and brought it to the MRI facility so they could resubmit it.

 

[bagelchick]

I just can't see an imaging facility administering an MRI without insurance verification and authorization.
This is a failure on many levels.
1-PCP needed to submit for pre-approval.
2-Patient then receives authorization.
3-Diagnostic imaging center verifies the authorization.
This is awful.

I had a $700 lab test done that I later found out wasn't covered by my plan. They took my insurance card and everything, but never bothered to tell me that that facility didn't accept my insurance. Then I got the bill.

 

[Simon_Cowbell]

If my doctor is in an approved network, ANY procedure they recommend must be covered.

If you are in a network, you know what is approved and what isn't.

I wouldn't pay one cent of a claim for a procedure done by an in-network doctor. Eventually, it will be dealt with.

 

[Ace]

If my doctor is in an approved network, ANY procedure they recommend must be covered.

If you are in a network, you know what is approved and what isn't.

I wouldn't pay one cent of a claim for a procedure done by an in-network doctor. Eventually, it will be dealt with.

Depends on the insurance, Simon.

You could have an in-network doctor recommending and MRI but the facility he sends you to is out of network. This happends a lot.

 

[Sam Mills 51]

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.

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

Negative. Many non-profit health care systems use banks for interest-bearing loans. Not doing so gives customers the impression that it's otherwise a lending institution, a big no-no for non-profits.

S-P, as usual, is spot-on. So many different rules for different insurance companies and, to take a step further, different for different levels of coverage within the same company. And to echo Ace, take detailed notes of who or what is considered in-network and out-of-network by your provider ... most physicians and private practices aren't jumping through those hoops for you.

There are more Bouncing Bettys to maneuver around than are still planted in Southeast Asia.