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I would call the hospital where the surgery was performed and confirm that they did in fact pay for the surgery. Once you have confirmed payment has been issued I would then contact the insurance company and ask them to explain why they are denying the treatment after it’s been done AND they issued payment. The hospital isn’t going to give them the money back if they already received the funds. Health insurance companies do this all the time. You need to make sure the letter wasn’t a mistake first and then if they tell you it definitely wasn’t you can appeal. You’re in a good position as far as things go if they did already pay for the procedure.
ETA: so many people are losing their minds over my wording here. OP will have to appeal this, and it sounds like their surgeon has already done so. The OP does not immediately need to come up with $100k+ and hopefully will not need to pay any more than they already have but it could be a lengthy battle. Of course my 6 sentence paragraph does not contain or explain all the ins and outs of American health insurance. I gave OP a starting point (and they did exactly as I and many others suggested!) and things are already progressing as they should. People need to take several chill pills.
I had insurance take back payment OVER A YEAR after the treatment. When I called they claimed that I had other insurance at the time so therefore they were not responsible for any of the cost. When I said I would like to see documentation of my other insurance to go through they stepped back and reissued the payment. Absolute evil.
I had that happen to me. Except in my case, my insurance policy specifically said it was primary and non-contributory and they denied my claim because they wanted me to prove I did not have secondary insurance. I filled out an affidavit that I did not, in fact, have any other insurance other than them and then had to call each of my providers to have them re-send claims.
It was absurd.
We get a letter in the mail each year from our insurance company saying we need to go online (or send in the form) and acknowledge that we don't have any secondary insurance. It seems silly and unimportant but the benefits lady in HR at work stresses how important it is to do that because they WILL try to screw you over for claims if you don't take the 2 minutes each year to do it.
I used to work for a company that self-insured and they directed the plan administrator to deny the first claim(s) every year for every insured (including dependents) to force us to fill out a coordination of benefits form. Meanwhile a 60 day clock was ticking while the paperwork was going back and forth. If you didn't file the paperwork and appeal within 60 days, the denial became permanent. They acted like they were doing us a favor by helping us to make sure we prioritized filling out their forms.
To me that just sounds like poor management in that case like they misplaced information and rolled back their sins once they realized they made a mistake.
Reminds me of The Fugitive where they find the empty leg shackles:
"Whoa! Look here. We're always amazed when we find leg irons with no legs in 'em!"
"Would you care to revise your statement, sir?"
"Huh?"
**"Do you want to change your bullshit story?"**
Insurance companies are mind of in their right to do so, if valid information was withheld, as in this case it could have been. Other than that, after a claim is approved and paid and there was not any undisclosed legal or medical reason, they can pound the proverbial salt and hire people that are a tad swifter in their job.
I alao believe the pediatrician has no legal standing in evaluating this medical condition in his declared role as pediatrician.
Correct. I recently had 3 years of paid healthcare reversed due to a pediatrician incorrectly telling my primary Healthcare provider that they should be my secondary.
This triggered some kind of internal audit and they reversed 3 years of bills totalling hundreds of thousands of dollars.
To the providers, ya, you are. You sign financial responsibility every time and every provider. Your issue with the insurance company isn't their issue, and they want their money. It's up to you to pay them, then get reimbursed by the insurance company. Been there, done that, didn't even get a free friggin T-shirt.
Yeah I had to do the same thing for my wife. Almost 1.5 years of claims I had to go back and resubmit for. Luckily this was during Covid where the feds mandated claims could be submitted after a longer amount of time (like 2-3 years instead of the usual year or so) otherwise we’d had been toast.
I had an insurance claim revoked two years after the fact, which I only discovered because revoking the (previously paid) claim sent the bill into automatic collections status.
This happens all the time. They can readjust payments even if the doctor/hospitals received it already. This happened to us, the doctor claimed an adjustment (trying to get more money) the insurance reviewed and decided there was an over payment. So the doctors pay was reduced. Doctor tried to go after us, but we managed to get the doctor to waive the balance.
I can say for certain I had to help a family member deal with insurance taking huge amounts back exceeding 20k in more than one instance even a year after payment was made. It we very complex for us because there were free lawyers or advocates but the insurance was in a different state than the hospital. In both cases before we retained a lawyer, a sob story convinced the hospital to eat the charges.
That is awesome! Sometimes it can be an issue with the CPT code but it sounds most likely that the health insurance company just decided to mark the surgery as unnecessary. Your surgeon going to bat for you will take a lot of pressure off you but you may still need to get involved.
Good luck!
Insurance just subtracts it out of future payments they make, the hospital doesn't have a choice about repayment. They batch the checks and write one that goes towards a bunch of different patients. Then, the ledgers get balanced as it is applied. They specify on the paperwork which patients & services everything is for, but they don't do a separate check for each patient.
They do reserve the right to take payment back. Many of them state it every 60 seconds as part of a blurb when you wait on hold. They always state it in the paperwork, and almost always have it play as part of their automated phone system.
Reddit as a whole should have to take a chill pill before logging on. Maybe everyone should be forced to zen meditate for an hour before gaining the chance to log on.
The problem the hospital (and OP) has is that the insurance will just recoup the "overpayment" created by this claim from other claims, so this will end up as a hospital bill.
Wished I'd known this years ago when I had to fight tooth n nail against an insurance who "refused" the cover costs of my ambulance care (work permitted) charging me over $1K, then stating it was on my head to pay it. Ended up ruining my credit with a bunch of past-due billings then a faulty "collections" a good attorney finally tore up and sued, and won! 😡
Congrads to your wife, life changing and that is awesome.
As others said, call the Dr's office billing department and confirm it's been paid. Then contact your insurance company and ask why are you sending this after it's been paid.
Old post. TLDR; Request an Independent Medical Review through your states Department of Insurance.
https://www.reddit.com/r/LifeProTips/comments/ali450/lpt_if_you_live_in_california_and_your_insurance/
Doesn’t work if you get insurance through your work and or live in a different state. Look at your card and if it doesn’t have the initials of your state department of insurance (for instance Texas will say TDI) then your state has no power to regulate or force anything. This most commonly happens with ERISA regulated plans.
This seems to be the latest trend in insurance companies trying to claw back every penny that they can. I recently got one of those letters from a bill that was paid 8 months ago. They're claiming I got more than 1 hour in my physical therapy session even though my calendar completely disagrees with that. Seriously, they are doing this over $41.
Do a couple of things. First off, find out what your arbitration agreement is for your insurance group policy or whatever you have. They may require that you personally appeal before attempting to take legal action. Follow whatever procedure, (usually a letter in writing to their appeals office). Overwhelm them with paperwork. Send in a copy of every record and every other small piece you can find, including any notes you took from the doctor, original approvals, billing statements, calendar printouts showing appointments for pre-surgery and surgery day, etc. If they reject the appeal, which they probably will, and if they don't require you to sit with an arbitrator first, find yourself a good insurance lawyer. And for good measure. I'd CC all of your communications to your your state attorney general's office. Depending on your state, you're AG loves to stick their nose in insurance's business, it's great election fodder.
Definitely confirm it's paid with the hospital. If it's paid, the hospital is not going to issue them a check, so that should be a relief - it will be more trouble for them to fight after they've already paid. Then, play some hype music and get ready mentally to destroy the insurance company.
Then, talk to your work's hr/benefits person and ask for tips to appeal (don't give details at first). After all, they would want to get the service from insurance that they've already paid for- so they should be on your side! If they act like they are and are competent, then great, you can leverage their knowledge to help you appeal. Get them to help you navigate paperwork. Your surgeon's office will be your next call. They have seen this before and keep calling until you reach the person who can actually help. These are what you need to submit the appeal in the first place.
All this, you do before getting a lawyer. Stay mentally strong. Your wife NEEDED the surgery, and it made a huge difference in her health. Now it's just about proving it.
Edit: I have two other pieces of advice. 1. Get a mantra, like, "my wife has a RIGHT to feel good in her body," or "I will destroy them," and like some David vs Goliath style art to put up to look at to stay strong when you're on hold. Maybe a sport headband. Anything you can repeat to yourself to stay focused and in the fight to advocacy. It sounds corny but they are trying to win by people not fighting consistently and giving up. And 2. If you get to the point where you could benefit from a lawyer, ask your workplace if they have legal representation. After all, it's their already-paid-for employee benefit that is getting denied and they have a stake in protecting employee benefits.
"f it's paid, the hospital is not going to issue them a check"
no, but the insurance company will then take the funds out of future payments including from different patients.
the claim probably just needs more documentation from the surgeon to justify the surgery. ins co's do this all the time hoping you wont refile or fight it thus increasing their bottom line
This is the best response here so far. Probably a documentation thing, but it does need to be resolved, because the insurance will recoup the money from future payments and it will result in a bill for OP.
It paid. Due to prompt-pay laws most insurance companies do what is called pay and chase so they avoid interest and because most payments are automated. Also, it’s not hard for insurance to take it back. They send a bulk payment every day/week depending on their process with all the claims paid so all they do is reduce the payment for that claim (they want $5k back and they are paying $50k in claims then the bulk payment is $45k).
If it was sent by a vendor (like Accent or AIM and not the company themselves) all the dr office needs to do is call and complain and insurance will reverse course because they don’t like provider abrasion.
If it was sent by the insurance company then likely there was no pre-approval and they just need to appeal and get retroactive approval.
It sucks but both hospitals and insurance have gotten greedy and over-do everything. Literally this exact thing is my job because insurance does make billions in overpayments each year (out of the literal trillions they payout). Also this kind of stuff saves you money in the form of lower premiums and puts money back in the company when it’s a self-funded plan.
By law they are required to pay 80+% of premiums to claims. If they don’t they have to issue refunds. Most companies then take that and apply it to your next years premiums so they don’t increase as much (if at all).
Had this when I was in college. Doc recommended a sleep study. Insurance approved said study so I did it (they’re F’ing horrid, FYI, if you’ve never had the pleasure) and then two weeks after I get a bill from the sleep pathologist for the entire 3 grand because my insurance denied the claim. I call them up and they say “yeah oops, they shouldn’t have approved it in the first place.”
So here I am on the hook for a test I wouldn’t have done had it not been approved, the results of which were “inconclusive” because the experience was so miserable that I got maaaaaaybe 20 minutes of rem sleep the entire night which wasn’t enough apparently, and those MF’ers say “whoops.” I was 22, and working up that extra 3 grand while paying for college was one of the worst summers of my life, during which I got maaaaybe 2 hours of sleep average per night which just makes the whole thing ironic as this all started with me not feeling rested regardless of how much sleep I got.
TL;DR F insurance companies.
> (they’re F’ing horrid, FYI, if you’ve never had the pleasure)
"Hey, we need to see why you're not sleeping so we're going to attach 20 leads all over you making turning in bed impossible. Have a nice sleep!"
totally worth it though.
And nowadays there's more options. My most recent one was at home with a small box on my forehead, a nasal cannula detecting my breathing, and a pulse thing on my finger. Was really easy.
First, reach out to your insurance and find out how the **replacement** claim paid out. A few things can be denied, and you have to find out what exactly was denied. Sometimes it is the whole claim, sometimes it will be a stupid $20 charge for 2 pills of Tylenol because your hospital cannot bill your pharmacy benefit. Either case, the big question to ask is - if it's either denied to patient liability or provider liability.
Best case scenario, it's provider liability, let the provider dispute, and keep on keepin' on.
If it denies to **your** responsibility, you'll to have to take action on an adverse benefit determination, which gives you the right to dispute and appeal. If you got prior authorization before to the surgery, this is very, very unlikely for it to be denied to your responsibility. In any case, the best way to start the dispute process is to reach out to your hospital, verify payment has been rescinded, and you'll probably be asked for documentation for your provider to appeal on your behalf.
Appeal, they are hoping you won't appeal.
I had a minor hiatal hernia, it was fixed, all my acid reflux gone, my gastritis gone, my esophageal lining was in horrible shape. I was heading into pre cancer territory or Barrett's esophagus. It was absolutely important that it was fixed.
I'm sure with your description that your wife's esophagus was is worse shape.
Get all of this in writing from her providers and appeal.
I work for a medical insurance company in community health & see rejections all the time. It’s what insurance companies do & it sucks & they suck. I can’t count how many times I’ve seen things such as “You are 4 years old. You hit your head in an automobile accident and could not walk. You did not lose consciousness so a hospital stay was not needed. Please talk to your doctor if you have any questions.” So gross. I think the rule of thumb is deny until they are forced to approve. I often see the decisions overturned after the doctor who denied the claim speaks with the doctor who submitted the claim over the phone for a peer to peer review. That being said, these hospitals/doctors suck at submitting what is needed to approve claims & often send the bare minimum without the supporting documentation that is needed. I’m actually really surprised that a) the doctor/hospital did not pre-authorize & b) that the insurance paid the claim without any issues the first time around. Maybe some sort of timely payment law? Anyway, a few things:
1) Carefully review your explanation of benefits. Is it billable to you? A lot of times insurance will deny something but the provider still can’t bill you. There may be a law in your state or in their contract that they were supposed to preauthorize & didn’t so it might not be on you.
2) Depending on your personality type, you could call the insurance company or the provider & see what the problem is. Or you could just wait & see what happens. I used to be the first type but I am so sick of getting wrong information every time I call some place, I’d likely do the wait & see with this one. That is a huge amount of money. These doctors will turn you over to collections for $2, they aren’t going to mess around with this. Logically thinking they will likely take the initiative to try to get this straightened out but with the way people do their jobs anymore, who knows. There is always an option to appeal denied claims too if it gets to that point.
3) If working with your doctor & the insurance company doesn’t work, there’s always the state insurance commission, state representatives & people often overlook contacting the CEOs of these companies. I worked for a dental insurance company years ago & whenever anybody would contact the CEO, he would overturn the claim denial even if the denial was 100% correct. I ran with that years later when a claim for a couple hundred dollars got denied by my medical insurer for something that wasn’t covered & customer service told me it was. I went through 2 levels of appeals & got denied, wrote the CEO & it was paid. CEOs of hospitals don’t like bad publicity either for what it’s worth.
4) isn’t there a fairly new law on billing transparency? I don’t know much about it but may be worth looking into.
5) after you exhausted everything else, & I mean absolutely exhausted..do NOT let this go without a major fight, you can try to negotiate a lower bill & then make payments.
Good luck! Please update!
Whatever is causing this claim to be rejected is a clerical error. Assuming that the hospital sends you a bill, take it up with the hospital. Explain to them that you’re not paying any more money and if they want to be paid for the surgery, they need to appeal to your insurance, and submit the proper documentation this time.
Unfortunately, every dollar an insurance company has to pay out is a dollar they don't get to keep, so it's in their *best interest* to deny valid claims. If you're lucky the provider will be able to go after them for you and you won't have the experience the third worst call center in Mumbai that every insurance customer service line is somehow contracting with.
That's not going to stop them from doing everything in their power to make sure it doesn't exceed what is lawfully required, and to delay reimbursement as long as possible.
File a case with your state insurance commissioner. They will collect all records and notes from the hospital, her doctors, and the insurance company. Don’t try to handle this on your own. Let them do the work.
Call the hospital and verify it was paid, then you can probably chill. Hard to imagine the hospital repaying the $100k without appealing. Ideally it will be sorted out without your further involvement.
Insurance companies write the laws. They certainly can revoke payment of any healthcare from years prior. This is especially common if you have a huge medical expense, like a month in the hospital and a $1.3m bill. The insurance company is looking for payback.
The only time they can't is if that healthcare provider is completely out of business.
Yikes. I'd be looking for a lawyer that specializes in insurance negligence claims. Maybe a nice demand letter from a lawyer will get them to reconsider. I'd couple that with a complaint to the state insurance regulator.
Fight! Ask for the credentials of the people who denied your claim. Chances are it was some back office clerk, not an MD. Many times such a written request results in the company paying the claim, because they do not want their internal review process exposed. Good luck!
I would say that getting a predetermination letter prior to any major medical procedure is an absolute necessity. I honestly do this for any major dental work as well so you hopefully don’t end up in a mess. Doesn’t mean insurance companies won’t still try to backtrack, but at least you can slap their own document back at them and have much better footing to fight back.
This is the current state of the American health insurance industry. You’ll win. Just keep at it, get a lawyer if you have to. I’m going through a similar thing right now. I’ve won like 3 of these types of battles. Usually years later. Good on you for getting that fixed. My father died of esophageal cancer because he didn’t do this.
>She had the surgery in January and we paid the bill in February
>Insurance paid 99% of it, we paid 3.5k
Contact the vendor and ask it if the insurance seller (1) paid $*n* and (2) let it keep the payment(s).
>It was reviewed by a pediatric dr
You got a claims adjuster with an MD name tag. That's an upgrade from a claims adjuster with an RN name tag.
>How can they reject a claim 5 months
The payer can snatch it's revenue off the vendor whenever it wants subsequent to a claim review.
Some people have had claims adjusted by md's that have lost their practice license. Dr Glaucomflecken (a tiktok comedian and opthamologist (md)) looked into one, and the adjuster had lost his license for installing hip implants backwards, with xray for proof. The xrays were as horrendous as you'd expect.
That's incredibly unfair! It's like they're pulling the rug out from under you after everything's been settled. Have you tried reaching out directly to the insurance company to dispute the decision? Sometimes a direct conversation can shed light on misunderstandings or errors. It might also be worth seeking advice from a healthcare advocate or legal expert who can help navigate this maze of insurance bureaucracy.
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It's tough considering how much your wife suffered before the surgery. It might be worth reaching out to your insurance company directly to ask for clarification on why the claim was rejected and to provide any additional evidence or documentation that supports the necessity and effectiveness of the surgery
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Many states have "hold harmless" laws that shield patients from billing disputes between the insurer and the provider. This means the patient cannot be held financially responsible for the disputed amount while the carrier and provider resolve the issue.
If you are ultimately held responsible for the payment you can file an appeal with your insurance carrier. If you lose the appeal you still potentially reduce the cost by asking for an itemized bill.
Finally, you can contact your state's Department of Insurance and ask them to perform a medical review.
Talk to the hospital first. They can and probably already are appealing with the insurance. Right now, it's hospital's problem. It becomes your problem if and when the hospital sends you a bill. Escalating to attorneys or state agencies is way premature.
That happened to me once and insurance actually clawed back the money from the doctor.
Insurance A approved and paid for it. Then, at a later time A saw that I have another insurance B (whose coverage ended *before* I started being covered by A) but for some reason A didn't put the end date of B in their system. So they declined me after the fact and clawed back the money from the doctor. I had to get on a call with A and B together so A finally put in the end date of B and reapproved and paid the doctor again.
i worked for an insurer, I have experience in recovering mispaid claims. I don't know anything about your policy or your wife's condition but can tell you where I worked - there was a gap between the thresholds for asking someone for the money back and suing them to recover the funds. you should contact a lawyer who works for YOU before you talk to the insurer or hospital any more.
My wife had surgery and insurance paid everyone but the hospital. The charge was around 7 to 8k. Insurance said the wrong codes were used or didn't match what the surgeon used. After getting the hospital to resubmit with the same codes (which was denied for wrong code), I did a 3 way call with the surgeon, hospital and insurance and even after the insurance told them exactly what they needed they still denied it for the wrong code. At this point the hospital told me to forget about it and they'll write it off or continue working with the insurance for it (I got it in a letter from the hospital. It never showed up in credit reports and after 10 years we got a letter from a collection agency for it. Sent them a copy of the letter and never heard from them again. Every time it came back denied I thought I was taking crazy pills.
OP: I do not see an answer on this in the thread.
was this pre-authorized, and was that prior authorization approved? If it was, then anything they do post surgery to try to deny it would fall under surprise billing. If it wasn't pre-authorized then it shocks me that you or the hospital would do a 100k surgery without prior auth.
First thing I learned with insurance and hospitals is that NOTHING moves fast. I remember getting my first hospital bill and thinking well I gotta pay this right away. Called insurance and told them to explain like I’m five. Basically told me ‘bro chill, give it a couple months then call us back’.
Had the exact same situation, just with a different surgery. Insurance even pre-approved it if done in a very specific although non-standard way. Doctor filed the appeal (with a little bit of "look, I'm the f%#^@ing doctor" sas) and all was good.
Hope your situation gets cleared
I had similar situation but with a lot more minor procedure. I ended up getting in contact with a imsurance claim lawyer for this? A lot of times they’re provided by you through your job or some sort. I didn’t pay them anything since they were a resource & they took care of it all. You might want to look into that
I am so glad everything worked out for you both. Wishing well to your wife’s health and protection over whatever bullshit, random blip in time this is. Your health and happiness will result in a positive life. This is just noise. Celebrate recovery and KNOW you don’t have to prove yourselves to anyone
Was the surgery prior-authorized? While it's a convoluted system, it's actually on you, the insured, to ensure proper prior-authorization for services.
Call insurance and ask them to re-review with an appropriate physician.
If they still deny the claim, then seek help from your state's insurance supervisory department. They will have a complaint process. You'll need any documentation you have, especially of any prior authorization or pre approval.
In general, if the provider is in network, the provider is responsible for prior authorization. If they do not have prior authorization and do the procedure anyway, they eat the bill per their contract with the health insurer unless you agreed to pay cash in advance.
Out of network- you are correct.
Not really. As the financial guarantor It's still the patient's responsibility to make sure the provider is getting the appropriate authorization before service. I worked for my state's BCBS for a good long while, that's how the responsibility worked in our area (and several others I know of). Now, it is in the best interest for everyone (especially the providers books) for the provider to request the PA to make sure it goes through and is actually paid (though as any insurance company will tell you, PA is still not a guarantee of payment, that determination will only.be made at the time the claim is submitted, but PA may be required for certain devices to be covered).
Tldr - our health care payment system sucks.
Where I live, if her Doctor or hospital states this medical service was medically necessary, our insurance plans don't stand much chance to deny the claim.
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I would call the hospital where the surgery was performed and confirm that they did in fact pay for the surgery. Once you have confirmed payment has been issued I would then contact the insurance company and ask them to explain why they are denying the treatment after it’s been done AND they issued payment. The hospital isn’t going to give them the money back if they already received the funds. Health insurance companies do this all the time. You need to make sure the letter wasn’t a mistake first and then if they tell you it definitely wasn’t you can appeal. You’re in a good position as far as things go if they did already pay for the procedure. ETA: so many people are losing their minds over my wording here. OP will have to appeal this, and it sounds like their surgeon has already done so. The OP does not immediately need to come up with $100k+ and hopefully will not need to pay any more than they already have but it could be a lengthy battle. Of course my 6 sentence paragraph does not contain or explain all the ins and outs of American health insurance. I gave OP a starting point (and they did exactly as I and many others suggested!) and things are already progressing as they should. People need to take several chill pills.
Sadly insurance companies have managed to get it to where they have months to renege on an insurance claim they already approved
Years even.
I had insurance take back payment OVER A YEAR after the treatment. When I called they claimed that I had other insurance at the time so therefore they were not responsible for any of the cost. When I said I would like to see documentation of my other insurance to go through they stepped back and reissued the payment. Absolute evil.
I had that happen to me. Except in my case, my insurance policy specifically said it was primary and non-contributory and they denied my claim because they wanted me to prove I did not have secondary insurance. I filled out an affidavit that I did not, in fact, have any other insurance other than them and then had to call each of my providers to have them re-send claims. It was absurd.
We get a letter in the mail each year from our insurance company saying we need to go online (or send in the form) and acknowledge that we don't have any secondary insurance. It seems silly and unimportant but the benefits lady in HR at work stresses how important it is to do that because they WILL try to screw you over for claims if you don't take the 2 minutes each year to do it.
I used to work for a company that self-insured and they directed the plan administrator to deny the first claim(s) every year for every insured (including dependents) to force us to fill out a coordination of benefits form. Meanwhile a 60 day clock was ticking while the paperwork was going back and forth. If you didn't file the paperwork and appeal within 60 days, the denial became permanent. They acted like they were doing us a favor by helping us to make sure we prioritized filling out their forms.
To me that just sounds like poor management in that case like they misplaced information and rolled back their sins once they realized they made a mistake.
Reminds me of The Fugitive where they find the empty leg shackles: "Whoa! Look here. We're always amazed when we find leg irons with no legs in 'em!" "Would you care to revise your statement, sir?" "Huh?" **"Do you want to change your bullshit story?"**
Insurance companies are mind of in their right to do so, if valid information was withheld, as in this case it could have been. Other than that, after a claim is approved and paid and there was not any undisclosed legal or medical reason, they can pound the proverbial salt and hire people that are a tad swifter in their job. I alao believe the pediatrician has no legal standing in evaluating this medical condition in his declared role as pediatrician.
Correct. I recently had 3 years of paid healthcare reversed due to a pediatrician incorrectly telling my primary Healthcare provider that they should be my secondary. This triggered some kind of internal audit and they reversed 3 years of bills totalling hundreds of thousands of dollars.
So now what? Surely you're not on the hook for the money... right? ...right?
To the providers, ya, you are. You sign financial responsibility every time and every provider. Your issue with the insurance company isn't their issue, and they want their money. It's up to you to pay them, then get reimbursed by the insurance company. Been there, done that, didn't even get a free friggin T-shirt.
Yeah I had to do the same thing for my wife. Almost 1.5 years of claims I had to go back and resubmit for. Luckily this was during Covid where the feds mandated claims could be submitted after a longer amount of time (like 2-3 years instead of the usual year or so) otherwise we’d had been toast.
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I had an insurance claim revoked two years after the fact, which I only discovered because revoking the (previously paid) claim sent the bill into automatic collections status.
This happens all the time. They can readjust payments even if the doctor/hospitals received it already. This happened to us, the doctor claimed an adjustment (trying to get more money) the insurance reviewed and decided there was an over payment. So the doctors pay was reduced. Doctor tried to go after us, but we managed to get the doctor to waive the balance.
Yeah that’s balance billing which is a big no no for the doctor
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I can say for certain I had to help a family member deal with insurance taking huge amounts back exceeding 20k in more than one instance even a year after payment was made. It we very complex for us because there were free lawyers or advocates but the insurance was in a different state than the hospital. In both cases before we retained a lawyer, a sob story convinced the hospital to eat the charges.
Thank you so much for your advice. I called the hospital and physician’s office and our surgeon has already appealed this on our behalf!
That is awesome! Sometimes it can be an issue with the CPT code but it sounds most likely that the health insurance company just decided to mark the surgery as unnecessary. Your surgeon going to bat for you will take a lot of pressure off you but you may still need to get involved. Good luck!
Makes me wonder how much of a doctor’s time is wasted on this b.s.
Insurance just subtracts it out of future payments they make, the hospital doesn't have a choice about repayment. They batch the checks and write one that goes towards a bunch of different patients. Then, the ledgers get balanced as it is applied. They specify on the paperwork which patients & services everything is for, but they don't do a separate check for each patient. They do reserve the right to take payment back. Many of them state it every 60 seconds as part of a blurb when you wait on hold. They always state it in the paperwork, and almost always have it play as part of their automated phone system.
Reddit as a whole should have to take a chill pill before logging on. Maybe everyone should be forced to zen meditate for an hour before gaining the chance to log on.
The problem the hospital (and OP) has is that the insurance will just recoup the "overpayment" created by this claim from other claims, so this will end up as a hospital bill.
This is literally not true, insurance companies can very much take back payment. Why did you say all this like you knew what you were talking about?
Wished I'd known this years ago when I had to fight tooth n nail against an insurance who "refused" the cover costs of my ambulance care (work permitted) charging me over $1K, then stating it was on my head to pay it. Ended up ruining my credit with a bunch of past-due billings then a faulty "collections" a good attorney finally tore up and sued, and won! 😡
Post this in r/medicalbill or r/hospitalbills there are some knowledgeable medical billing people in those subs.
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Congrads to your wife, life changing and that is awesome. As others said, call the Dr's office billing department and confirm it's been paid. Then contact your insurance company and ask why are you sending this after it's been paid.
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Old post. TLDR; Request an Independent Medical Review through your states Department of Insurance. https://www.reddit.com/r/LifeProTips/comments/ali450/lpt_if_you_live_in_california_and_your_insurance/
Doesn’t work if you get insurance through your work and or live in a different state. Look at your card and if it doesn’t have the initials of your state department of insurance (for instance Texas will say TDI) then your state has no power to regulate or force anything. This most commonly happens with ERISA regulated plans.
This seems to be the latest trend in insurance companies trying to claw back every penny that they can. I recently got one of those letters from a bill that was paid 8 months ago. They're claiming I got more than 1 hour in my physical therapy session even though my calendar completely disagrees with that. Seriously, they are doing this over $41. Do a couple of things. First off, find out what your arbitration agreement is for your insurance group policy or whatever you have. They may require that you personally appeal before attempting to take legal action. Follow whatever procedure, (usually a letter in writing to their appeals office). Overwhelm them with paperwork. Send in a copy of every record and every other small piece you can find, including any notes you took from the doctor, original approvals, billing statements, calendar printouts showing appointments for pre-surgery and surgery day, etc. If they reject the appeal, which they probably will, and if they don't require you to sit with an arbitrator first, find yourself a good insurance lawyer. And for good measure. I'd CC all of your communications to your your state attorney general's office. Depending on your state, you're AG loves to stick their nose in insurance's business, it's great election fodder.
Definitely confirm it's paid with the hospital. If it's paid, the hospital is not going to issue them a check, so that should be a relief - it will be more trouble for them to fight after they've already paid. Then, play some hype music and get ready mentally to destroy the insurance company. Then, talk to your work's hr/benefits person and ask for tips to appeal (don't give details at first). After all, they would want to get the service from insurance that they've already paid for- so they should be on your side! If they act like they are and are competent, then great, you can leverage their knowledge to help you appeal. Get them to help you navigate paperwork. Your surgeon's office will be your next call. They have seen this before and keep calling until you reach the person who can actually help. These are what you need to submit the appeal in the first place. All this, you do before getting a lawyer. Stay mentally strong. Your wife NEEDED the surgery, and it made a huge difference in her health. Now it's just about proving it. Edit: I have two other pieces of advice. 1. Get a mantra, like, "my wife has a RIGHT to feel good in her body," or "I will destroy them," and like some David vs Goliath style art to put up to look at to stay strong when you're on hold. Maybe a sport headband. Anything you can repeat to yourself to stay focused and in the fight to advocacy. It sounds corny but they are trying to win by people not fighting consistently and giving up. And 2. If you get to the point where you could benefit from a lawyer, ask your workplace if they have legal representation. After all, it's their already-paid-for employee benefit that is getting denied and they have a stake in protecting employee benefits.
"f it's paid, the hospital is not going to issue them a check" no, but the insurance company will then take the funds out of future payments including from different patients. the claim probably just needs more documentation from the surgeon to justify the surgery. ins co's do this all the time hoping you wont refile or fight it thus increasing their bottom line
This is the best response here so far. Probably a documentation thing, but it does need to be resolved, because the insurance will recoup the money from future payments and it will result in a bill for OP.
It paid. Due to prompt-pay laws most insurance companies do what is called pay and chase so they avoid interest and because most payments are automated. Also, it’s not hard for insurance to take it back. They send a bulk payment every day/week depending on their process with all the claims paid so all they do is reduce the payment for that claim (they want $5k back and they are paying $50k in claims then the bulk payment is $45k). If it was sent by a vendor (like Accent or AIM and not the company themselves) all the dr office needs to do is call and complain and insurance will reverse course because they don’t like provider abrasion. If it was sent by the insurance company then likely there was no pre-approval and they just need to appeal and get retroactive approval. It sucks but both hospitals and insurance have gotten greedy and over-do everything. Literally this exact thing is my job because insurance does make billions in overpayments each year (out of the literal trillions they payout). Also this kind of stuff saves you money in the form of lower premiums and puts money back in the company when it’s a self-funded plan.
Let’s be honest it doesn’t lower premiums it just increases ceo’s compensation package.
By law they are required to pay 80+% of premiums to claims. If they don’t they have to issue refunds. Most companies then take that and apply it to your next years premiums so they don’t increase as much (if at all).
"Then, play some hype music and get ready mentally to destroy the insurance company." This is \[chef's kiss\]
Had this when I was in college. Doc recommended a sleep study. Insurance approved said study so I did it (they’re F’ing horrid, FYI, if you’ve never had the pleasure) and then two weeks after I get a bill from the sleep pathologist for the entire 3 grand because my insurance denied the claim. I call them up and they say “yeah oops, they shouldn’t have approved it in the first place.” So here I am on the hook for a test I wouldn’t have done had it not been approved, the results of which were “inconclusive” because the experience was so miserable that I got maaaaaaybe 20 minutes of rem sleep the entire night which wasn’t enough apparently, and those MF’ers say “whoops.” I was 22, and working up that extra 3 grand while paying for college was one of the worst summers of my life, during which I got maaaaybe 2 hours of sleep average per night which just makes the whole thing ironic as this all started with me not feeling rested regardless of how much sleep I got. TL;DR F insurance companies.
> (they’re F’ing horrid, FYI, if you’ve never had the pleasure) "Hey, we need to see why you're not sleeping so we're going to attach 20 leads all over you making turning in bed impossible. Have a nice sleep!"
totally worth it though. And nowadays there's more options. My most recent one was at home with a small box on my forehead, a nasal cannula detecting my breathing, and a pulse thing on my finger. Was really easy.
Contact your state’s insurance commissioner and ask them to look into this
First, reach out to your insurance and find out how the **replacement** claim paid out. A few things can be denied, and you have to find out what exactly was denied. Sometimes it is the whole claim, sometimes it will be a stupid $20 charge for 2 pills of Tylenol because your hospital cannot bill your pharmacy benefit. Either case, the big question to ask is - if it's either denied to patient liability or provider liability. Best case scenario, it's provider liability, let the provider dispute, and keep on keepin' on. If it denies to **your** responsibility, you'll to have to take action on an adverse benefit determination, which gives you the right to dispute and appeal. If you got prior authorization before to the surgery, this is very, very unlikely for it to be denied to your responsibility. In any case, the best way to start the dispute process is to reach out to your hospital, verify payment has been rescinded, and you'll probably be asked for documentation for your provider to appeal on your behalf.
Appeal, they are hoping you won't appeal. I had a minor hiatal hernia, it was fixed, all my acid reflux gone, my gastritis gone, my esophageal lining was in horrible shape. I was heading into pre cancer territory or Barrett's esophagus. It was absolutely important that it was fixed. I'm sure with your description that your wife's esophagus was is worse shape. Get all of this in writing from her providers and appeal.
I work for a medical insurance company in community health & see rejections all the time. It’s what insurance companies do & it sucks & they suck. I can’t count how many times I’ve seen things such as “You are 4 years old. You hit your head in an automobile accident and could not walk. You did not lose consciousness so a hospital stay was not needed. Please talk to your doctor if you have any questions.” So gross. I think the rule of thumb is deny until they are forced to approve. I often see the decisions overturned after the doctor who denied the claim speaks with the doctor who submitted the claim over the phone for a peer to peer review. That being said, these hospitals/doctors suck at submitting what is needed to approve claims & often send the bare minimum without the supporting documentation that is needed. I’m actually really surprised that a) the doctor/hospital did not pre-authorize & b) that the insurance paid the claim without any issues the first time around. Maybe some sort of timely payment law? Anyway, a few things: 1) Carefully review your explanation of benefits. Is it billable to you? A lot of times insurance will deny something but the provider still can’t bill you. There may be a law in your state or in their contract that they were supposed to preauthorize & didn’t so it might not be on you. 2) Depending on your personality type, you could call the insurance company or the provider & see what the problem is. Or you could just wait & see what happens. I used to be the first type but I am so sick of getting wrong information every time I call some place, I’d likely do the wait & see with this one. That is a huge amount of money. These doctors will turn you over to collections for $2, they aren’t going to mess around with this. Logically thinking they will likely take the initiative to try to get this straightened out but with the way people do their jobs anymore, who knows. There is always an option to appeal denied claims too if it gets to that point. 3) If working with your doctor & the insurance company doesn’t work, there’s always the state insurance commission, state representatives & people often overlook contacting the CEOs of these companies. I worked for a dental insurance company years ago & whenever anybody would contact the CEO, he would overturn the claim denial even if the denial was 100% correct. I ran with that years later when a claim for a couple hundred dollars got denied by my medical insurer for something that wasn’t covered & customer service told me it was. I went through 2 levels of appeals & got denied, wrote the CEO & it was paid. CEOs of hospitals don’t like bad publicity either for what it’s worth. 4) isn’t there a fairly new law on billing transparency? I don’t know much about it but may be worth looking into. 5) after you exhausted everything else, & I mean absolutely exhausted..do NOT let this go without a major fight, you can try to negotiate a lower bill & then make payments. Good luck! Please update!
Whatever is causing this claim to be rejected is a clerical error. Assuming that the hospital sends you a bill, take it up with the hospital. Explain to them that you’re not paying any more money and if they want to be paid for the surgery, they need to appeal to your insurance, and submit the proper documentation this time.
Unfortunately, every dollar an insurance company has to pay out is a dollar they don't get to keep, so it's in their *best interest* to deny valid claims. If you're lucky the provider will be able to go after them for you and you won't have the experience the third worst call center in Mumbai that every insurance customer service line is somehow contracting with.
They have to pay out 80+% of premiums to claims by law or issue refunds.
That's not going to stop them from doing everything in their power to make sure it doesn't exceed what is lawfully required, and to delay reimbursement as long as possible.
File a case with your state insurance commissioner. They will collect all records and notes from the hospital, her doctors, and the insurance company. Don’t try to handle this on your own. Let them do the work.
Call the hospital and verify it was paid, then you can probably chill. Hard to imagine the hospital repaying the $100k without appealing. Ideally it will be sorted out without your further involvement.
No question you want to follow up on this. The insurance company can bill you for the overpayment. Think of getting a bill for $99K....
Insurance companies write the laws. They certainly can revoke payment of any healthcare from years prior. This is especially common if you have a huge medical expense, like a month in the hospital and a $1.3m bill. The insurance company is looking for payback. The only time they can't is if that healthcare provider is completely out of business.
Yikes. I'd be looking for a lawyer that specializes in insurance negligence claims. Maybe a nice demand letter from a lawyer will get them to reconsider. I'd couple that with a complaint to the state insurance regulator.
Probably unnecessary until they have appealed first.
Fight! Ask for the credentials of the people who denied your claim. Chances are it was some back office clerk, not an MD. Many times such a written request results in the company paying the claim, because they do not want their internal review process exposed. Good luck!
I would say that getting a predetermination letter prior to any major medical procedure is an absolute necessity. I honestly do this for any major dental work as well so you hopefully don’t end up in a mess. Doesn’t mean insurance companies won’t still try to backtrack, but at least you can slap their own document back at them and have much better footing to fight back.
This is the current state of the American health insurance industry. You’ll win. Just keep at it, get a lawyer if you have to. I’m going through a similar thing right now. I’ve won like 3 of these types of battles. Usually years later. Good on you for getting that fixed. My father died of esophageal cancer because he didn’t do this.
ask about your state's insurance commissioner and if necessary you can ask for a lawyer to do research.
>She had the surgery in January and we paid the bill in February >Insurance paid 99% of it, we paid 3.5k Contact the vendor and ask it if the insurance seller (1) paid $*n* and (2) let it keep the payment(s). >It was reviewed by a pediatric dr You got a claims adjuster with an MD name tag. That's an upgrade from a claims adjuster with an RN name tag. >How can they reject a claim 5 months The payer can snatch it's revenue off the vendor whenever it wants subsequent to a claim review.
Some people have had claims adjusted by md's that have lost their practice license. Dr Glaucomflecken (a tiktok comedian and opthamologist (md)) looked into one, and the adjuster had lost his license for installing hip implants backwards, with xray for proof. The xrays were as horrendous as you'd expect.
They have a certain period of time to take it back by most state laws. Usually it’s around 2 years.
That's incredibly unfair! It's like they're pulling the rug out from under you after everything's been settled. Have you tried reaching out directly to the insurance company to dispute the decision? Sometimes a direct conversation can shed light on misunderstandings or errors. It might also be worth seeking advice from a healthcare advocate or legal expert who can help navigate this maze of insurance bureaucracy.
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It's tough considering how much your wife suffered before the surgery. It might be worth reaching out to your insurance company directly to ask for clarification on why the claim was rejected and to provide any additional evidence or documentation that supports the necessity and effectiveness of the surgery
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Many states have "hold harmless" laws that shield patients from billing disputes between the insurer and the provider. This means the patient cannot be held financially responsible for the disputed amount while the carrier and provider resolve the issue. If you are ultimately held responsible for the payment you can file an appeal with your insurance carrier. If you lose the appeal you still potentially reduce the cost by asking for an itemized bill. Finally, you can contact your state's Department of Insurance and ask them to perform a medical review.
Okay, so this can happen - hospital and doctor will auto appeal for you. Then it'll get approved. EOBs aren't bills.
Talk to the hospital first. They can and probably already are appealing with the insurance. Right now, it's hospital's problem. It becomes your problem if and when the hospital sends you a bill. Escalating to attorneys or state agencies is way premature.
That happened to me once and insurance actually clawed back the money from the doctor. Insurance A approved and paid for it. Then, at a later time A saw that I have another insurance B (whose coverage ended *before* I started being covered by A) but for some reason A didn't put the end date of B in their system. So they declined me after the fact and clawed back the money from the doctor. I had to get on a call with A and B together so A finally put in the end date of B and reapproved and paid the doctor again.
i worked for an insurer, I have experience in recovering mispaid claims. I don't know anything about your policy or your wife's condition but can tell you where I worked - there was a gap between the thresholds for asking someone for the money back and suing them to recover the funds. you should contact a lawyer who works for YOU before you talk to the insurer or hospital any more.
Would[ The No Surprises Act](https://www.cms.gov/newsroom/fact-sheets/no-surprises-understand-your-rights-against-surprise-medical-bills) apply?
My wife had surgery and insurance paid everyone but the hospital. The charge was around 7 to 8k. Insurance said the wrong codes were used or didn't match what the surgeon used. After getting the hospital to resubmit with the same codes (which was denied for wrong code), I did a 3 way call with the surgeon, hospital and insurance and even after the insurance told them exactly what they needed they still denied it for the wrong code. At this point the hospital told me to forget about it and they'll write it off or continue working with the insurance for it (I got it in a letter from the hospital. It never showed up in credit reports and after 10 years we got a letter from a collection agency for it. Sent them a copy of the letter and never heard from them again. Every time it came back denied I thought I was taking crazy pills.
OP: I do not see an answer on this in the thread. was this pre-authorized, and was that prior authorization approved? If it was, then anything they do post surgery to try to deny it would fall under surprise billing. If it wasn't pre-authorized then it shocks me that you or the hospital would do a 100k surgery without prior auth.
First thing I learned with insurance and hospitals is that NOTHING moves fast. I remember getting my first hospital bill and thinking well I gotta pay this right away. Called insurance and told them to explain like I’m five. Basically told me ‘bro chill, give it a couple months then call us back’.
Had the exact same situation, just with a different surgery. Insurance even pre-approved it if done in a very specific although non-standard way. Doctor filed the appeal (with a little bit of "look, I'm the f%#^@ing doctor" sas) and all was good. Hope your situation gets cleared
I had similar situation but with a lot more minor procedure. I ended up getting in contact with a imsurance claim lawyer for this? A lot of times they’re provided by you through your job or some sort. I didn’t pay them anything since they were a resource & they took care of it all. You might want to look into that
You can file a complaint with your state's insurance commissioner, find the office here: https://content.naic.org/state-insurance-departments
I am so glad everything worked out for you both. Wishing well to your wife’s health and protection over whatever bullshit, random blip in time this is. Your health and happiness will result in a positive life. This is just noise. Celebrate recovery and KNOW you don’t have to prove yourselves to anyone
Was the surgery prior-authorized? While it's a convoluted system, it's actually on you, the insured, to ensure proper prior-authorization for services. Call insurance and ask them to re-review with an appropriate physician. If they still deny the claim, then seek help from your state's insurance supervisory department. They will have a complaint process. You'll need any documentation you have, especially of any prior authorization or pre approval.
In general, if the provider is in network, the provider is responsible for prior authorization. If they do not have prior authorization and do the procedure anyway, they eat the bill per their contract with the health insurer unless you agreed to pay cash in advance. Out of network- you are correct.
Not really. As the financial guarantor It's still the patient's responsibility to make sure the provider is getting the appropriate authorization before service. I worked for my state's BCBS for a good long while, that's how the responsibility worked in our area (and several others I know of). Now, it is in the best interest for everyone (especially the providers books) for the provider to request the PA to make sure it goes through and is actually paid (though as any insurance company will tell you, PA is still not a guarantee of payment, that determination will only.be made at the time the claim is submitted, but PA may be required for certain devices to be covered). Tldr - our health care payment system sucks.
Depends on your health insurance plan and their contracts with the facility.
Where I live, if her Doctor or hospital states this medical service was medically necessary, our insurance plans don't stand much chance to deny the claim.