6 weeks Post-op, Insurance denied over 1/2 of hospital claim

Half denied

by AgentX86 - 2018-09-25 21:51:31

Exactly how was it denied?  In my case, the insurance never pays even half the bill but I still pay nothing.  This is a common situation.  Basically, the insurance company has contracted fees for each procedure and that's all they will pay, however that contract covers the patient as well.  It's one of the more important parts of insurance, in fact.  You get their buying power.

Now, the big question; are you being charged the difference?  You have been sent a bill for the difference?  If so, what is their reason?

6 weeks Post-op, Insurance denied over 1/2 of hospital claim

by DLynn - 2018-09-26 10:42:40

In response to comments, I have private insurance, Blue Cross /Blue Sheild,  After my Dr. visit on the 8/16 Dr. direct admitted me to hospital to have labs and MRI of my heart done to rule out any underlying condition or progressive heart disease that could be causing the Bradycardia with plan to have pacemaker inserted on the 17th.  In conversation with the insurance  they say that when they were contacted for the hospital admission it was denied and they then did a peer review and again it was denied.  I was never told about the denial, the first i knew that there may be a problem with payment was a week after I was home I received a statement from insurance saying they agreed that I needed a pacemaker but felt it should have been done with an observational stay rather than a full admit.  Now  the EOB (Estimate of Benefits) after insurance payment states I could be billed for over $32,000 in addition to my detuctible portion.  I have spoke to the billing dept. at the hospital who said they will be filing more paperwork with the insurance, but if they continue to deny then I would need to appeal.

Don't get too upset over this.

by AgentX86 - 2018-09-26 11:00:55

Just give them each any information and file any paperwork they want. The hospital isn't expecting you to pay this (it's an absurd amount). They'll eventually come to an agreement.

Obviously I don't know your insurance policy but mine states that if there are charges, that hadn't been preapproved, that are disputed, the hospital eats them. The insured, in no way, owes the money. The insurance company pays what the insurance company has contracted to pay and that's all they get. The insurance company has gone to bat for me a few times. It's one of the "big evil insurance companies ", too.

Bottom line: read your policy (if you can) and don't borrow trouble.

don't panic

by ROBO Pop - 2018-09-26 19:26:27

What is it with everybody jumping to the conclusion this person has Medicare? Read what the poster writes and don't look between the lines for stuff that ain't there. 

I get those "you may be billed $XXXX" all the time, and never hear from the hospital or doctors. I stopped worrying about it long ago. Still follow Robin's advice, well except the part about Medicare, and have some patience.

Have some patience

by AgentX86 - 2018-09-26 22:49:52

Indeed.  My son just showed me the paperwork where the insurance company finally got around to paying for the granddaughter's open heart surgery when she was 2-days old (swapped the aorta and pulmonary arteries).  They finally ponied up $300K.  BTW, she's now a 3-1/2 year-old terrorist (I love paybacks ;-).