Insurance is balking on covering my last surgery

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fashiongirl
Regular Member


Date Joined Jun 2010
Total Posts : 27
   Posted 7/11/2010 8:10 PM (GMT -7)   
I just got a letter this weekend saying that my insurance reviewed the files on my surgery and they didn't deem it necessary. So it's not covered. Just what I need to hear! It's like they want us to jump off a cliff!
sigh. Just gonna go crawl under a rock now...

Tirzah
Veteran Member


Date Joined Jul 2008
Total Posts : 2280
   Posted 7/11/2010 8:34 PM (GMT -7)   
May not help, but appeal it. Sometimes they deny stuff just to see if we'll accept the denial. If they deny your appeal, have your surgeon write them a letter (s/he should know what to say -- this happens far too often).

Sure hope they change their minds. So aggravating!
frances

fashiongirl
Regular Member


Date Joined Jun 2010
Total Posts : 27
   Posted 7/11/2010 8:48 PM (GMT -7)   
I'm calling my surgeon tomorrow to get them to do something. But that office is so incompetent that my hopes are not high...(I had to get my synvisc shot approved, ordered, and delivered. They can't do anything...)

skeye
Veteran Member


Date Joined Mar 2008
Total Posts : 2976
   Posted 7/11/2010 9:04 PM (GMT -7)   
Hi Fashiongirl,

I'm sorry to hear about your insurance troubles. I had my fair share of them this year, so I can relate. Did you already have the surgery, or is this for an upcoming surgery? If you already had the surgery, boy, how rotten!

Ask your surgeon if you can see a copy of the appeal letter before they send it in (or better yet, have them send the copy & materials to you & then you yourself submit the appeal to the insurance company). That way you can find out ahead of time whether or not your doctor wrote you a good letter.

During my second appeal, I made the mistake of trusting my doctor to write a good letter (he is a world renowned neurosurgeon, after all) & when I later saw it (after the denial of the second appeal/after exhausting my insurance's internal appeal process, while I was getting together all the paperwork to send my appeal to my state Insurance Commissioner for appeal) I was beyond horrified. It was the worst letter I'd ever seen. It must have taken 30 seconds to write, because it was about 2 lines & said absolutely nothing. I promptly wrote a strong letter to the Insurance Commissioner, detailing my argument, & forwarded a copy to my surgeon & asked him to rewrite his letter, using mine as somewhat of a guide. His second letter was a thousand times better. If I hadn't seen that letter & had continued to let my dr's office handle my appeals, then I doubt that I would have won my case. I can tell you this much, I won't make the same mistake next time.

Skeye

Draka
Regular Member


Date Joined Jun 2009
Total Posts : 256
   Posted 7/11/2010 9:31 PM (GMT -7)   
I'm sorry Fashiongirl.... but you are not alone... same thing happened to me and I, along with my PM office are appealing for the 4th time!

Ugh... how very frustrating... we pay and arm and leg for coverage and then they refuse....

I was refused.... get this... on the table... in the surgical suite... with an IV drip in my arm!!! No joke....

My husband and I are beyond disgusted and disheartened.

Call your insurance directly and ask them what they need in order for them to cover your procedure... I did with mine and I was told... first.. that my PM office put in the
wrong codes... the office re-submitted the claim with the corrected codes and it was denied again... this time they said they need a letter of medical necessity from the
Dr.... again my Dr's office put together a package and we are going for the 4th time! The claim is for $19,000... so fingers crossed!!!!

Best of luck with your claim and I hope you get what you need.

fashiongirl
Regular Member


Date Joined Jun 2010
Total Posts : 27
   Posted 7/11/2010 9:49 PM (GMT -7)   
Thanks everyone. Great advice! I had the surgery back in May and thought it was all by the book. But this is the second time this doctor's office has "messed" up something with insurance. A code or something is wrong. I'm making calls in the morning to figure out how to fix this. So stressful and frustrating.

Draka--they did that to you while you had an IV in your arm? Wow. That's just cold!!!

Tirzah
Veteran Member


Date Joined Jul 2008
Total Posts : 2280
   Posted 7/12/2010 6:01 AM (GMT -7)   
FG-
If it's just a coding error, you shouldn't need to waste an appeal. Ask them what the prior code was & what the new code is. Sometimes you can find the codes online -- if it's covered by Medicare you are very, very likely to eventually win an appeal/revision of coding. If you can't find the code online (and maybe it's a good idea even if you can), call your insurance company and ask them whether that code is typically covered. They won't abide by what they tell you, but write down their statement, the date/time of the call & the name of the rep anyways. If you have to appeal to the Div. of Insurance that is something you can include if the rep tells you it will be covered.

If they say it won't be covered, ask if they can provide any guidance on what the correct code might be (it's worked for me a little less than half the time). If they can't do that, ask them if they know why it's not being covered and if there's any additional information they can offer. Depending on your state, your doctors office has a set period of time to try billing under different codes (in IL it's 6 months; your insurer should be able to tell you what it is in your state). Don't miss that deadline. If you (read: your doctor) can't get the billing code correct by that deadline, your appeal rights may be affected. All hope isn't lost, but it makes it harder.

In the future, you might try asking for a Pre-Determination Letter. NOT a Pre-Approval Letter (those things are practically worthless). Your doctor needs to request it, but you can push his office to do so. Yes, it's a huge hassle & the insurance company will complain bitterly, but what other option have they left us? I've been screwed over so many times with those Pre-Approval Letters that it's ridiculous. I've learned to fight back better now, but it cost me a lot of money to learn that lesson.

take care,
frances

straydog
Forum Moderator


Date Joined Feb 2003
Total Posts : 13451
   Posted 7/12/2010 10:29 AM (GMT -7)   
I am glad Frances brought up the Pre-Determination Letter, she is right, it basically is not worth the paper it is written on because in the fine print it states this is not an authorization stating payment will be made. Many times folks misunderstand this. I hope you get this worked out.
 

crohns disease dx 2002 & small bowel resection, still looking for remission whatever that is, chronic pain 22 yrs, added ulcerative colitis 6-05 to the mix, high blood pressure 28 yrs, aortic heart valve insuffiency, depression, osteoarthritis, osteoporosis lumbar spine, scoliosis lumbar spine, peripheral neuropathy hands & feet, COPD & on oxygen therapy, lupus & psoriasis and psoratic arthritis. Several other health issues just not enough room to list it all. Too many surgeries to list and too many medications to list. Currently on 17 different daily medications. Intrathecal pain pump implanted June 05.


PAlady
Veteran Member


Date Joined Nov 2007
Total Posts : 6795
   Posted 7/12/2010 11:52 AM (GMT -7)   
Hi,
Frances is giving you some good advice, but keep in mind there are two types of codes: procedure codes and billing codes. An error on either one (and there are usually several of each for something as complicated as a surgery) can result in a denial.

Procedure codes are the coding for what the doctor and other medical professionals do. There will be a code for the main surgical procedure, but often several other codes for different aspects of the procedure such as the anesthesia, etc. Then the billing codes one would think would be the same, but they are not. That's why there's an entire department at hospitals (and usually a few people at each doctor's office) who are the coding specialists. They take a procedure code, look up the appropriate billing code, and bill under that.

So the insurance company has to first cover the procedure code, and like Frances indicated there may be several options they can choose from, and one might be covered by your insurance and another code not. You've got to see if you can find a procedure code your insurance company covers. I've often found the coding specialists at the doctor's office and/or hospital are the most helpful with this area, as they usually know the problems that arise. Then the correct billing code needs to be used. You'd be surprised how many coding errors there are and it is a complicated mess to straighten it out, but like Frances said if you get on it quickly you might be able to do it. It does take work on your part, though. A royal pain just when you don't need one.

Good luck!

PaLady

Retired Mom
Veteran Member


Date Joined Feb 2010
Total Posts : 1753
   Posted 7/12/2010 2:57 PM (GMT -7)   
I had the exact same thing happen for a procedure I had back in December of last year.  The nerve ablation was denied because it was considered experimental (even though it was pre-approved...as is the policy of the PM practice).  I'm still fighting it because of the pre-approval, but I'm afraid I'm going to be stuck in the long run.  I swear I even called the Dr's office the day before to make certain that I was OK with the pre-approval and they assured me that they NEVER do any procedure without pre-certification and that is why I had to have the "test" procedures (which were covered in full).  I'm kind of waiting on the shoe to fall on this one and to be hit with a serious bill because I'll be done paying the last 2000.00 on the brain MRI I had done at the beginning of January in July.  They would only allow a six month payment plan without a credit application and all that nonsense.  I refuse to apply for credit for a procedure I have already had done....that's insane!!  Of course, I do pay my bills....but a credit app for a hospital....give me a break!
 
Best to you on this one.  Appeal as quickly as possible in every way.  Make sure to have everything in writing to the insurance company and keep copies.  They tend to give an impossible timeline for dispute and if you don't turn it in by that date, they assume you agree with the decision made.
 
 
Retired Mom


Draka
Regular Member


Date Joined Jun 2009
Total Posts : 256
   Posted 7/12/2010 3:08 PM (GMT -7)   
fashiongirl said...

Draka--they did that to you while you had an IV in your arm? Wow. That's just cold!!!


Yes... it did happen and I promise you I am not making it up...

Frances... I will remember to ask for a pre-determination letter in the future if I ever need any more procedures... very
useful information.

fashiongirl
Regular Member


Date Joined Jun 2010
Total Posts : 27
   Posted 7/12/2010 5:03 PM (GMT -7)   
Great advice everyone, thank you! I called the insurance company today to find out what the exact issue was and they couldn't tell me. The letter said it was experimental? It was artho knee surgery for arthritis! My 4th! Not experimental! So I asked if the codes were incorrect. They couldn't tell me. I asked if any of the pre-certification documentation was missing. They couldn't tell me. So all in all, quite useless. So then I called my doctor's office, who received the letter as well, and they never called back. It seems no one cares about this but me. Great!

I'm going to try again tomorrow. Hopefully someone more helpful will be on the phone...

Tirzah
Veteran Member


Date Joined Jul 2008
Total Posts : 2280
   Posted 7/12/2010 6:04 PM (GMT -7)   
Calling back is a good idea. Also write them a letter. I've found that the people who are assigned to write letters tend to be slightly better (and I emphasize "slightly"). Plus, keep a copy of your letter & any responses you get (including brush-off's). Those can be used later if, heaven forbid, you have to file a complaint against them.

So sorry you're having a rough time, but hang in there. A decent number of times these things can be sorted out. They should at least be able to tell you what code it was filed under. Ask for the procedure & billing code. Sometimes it's even as simple as a coder mixing the two up (it happened to me a couple of times). I'll try to see if I can find that phone number I called the one time I really had trouble. It was for some US gov't office & they were very helpful to me. I don't even remember what the issue was that particular time, but I remember being surprised that I actually got a federal employee to answer the phone & help me in one try, without being on hold!

Pay the fee to get a copy of the letter from your doctor's office of any letters they've sent justifying the surgery. Trust me, it's worth it. Sometimes they're just covering up that they forgot to ever submit the documents. Better to find that out sooner rather than later. Man alive, being sick is a lot of work!!!

blessings,
frances

skeye
Veteran Member


Date Joined Mar 2008
Total Posts : 2976
   Posted 7/12/2010 7:19 PM (GMT -7)   
Fashiongirl,

In the denial letter, did they not tell you the reasons for denial? When I've gotten denials in the past, my insurance has always listed their reasoning. I'm surprised that no one was able to tell you why your procedure was denied. Maybe look at the letter again in case you missed something?

I don't envy you at all. I know that this insurance business is a real pain!

Skeye

fashiongirl
Regular Member


Date Joined Jun 2010
Total Posts : 27
   Posted 7/12/2010 7:53 PM (GMT -7)   
Skeye, the letter said the procedure was experimental and not considered useful for my condition. I have arthritis in my knee and this is my 4th arthoscopic knee surgery. I really don't know why they denied this one. I think perhaps the code was wrong and they think it's a more intense surgery than it was? So just trying to find out and get an answer. I'll try again tomorrow. THanks everyone. This is so nutty and frustrating! But I won't give up!

Tirzah
Veteran Member


Date Joined Jul 2008
Total Posts : 2280
   Posted 7/13/2010 4:48 PM (GMT -7)   
FG-
Just wanted to encourage you not to get too hung up on the idea that it was labeled "experimental". All that means is that the procedure is not FDA approved for your exact condition. The majority of procedures are only approved for one or two diagnoses, but are widely used to treat other conditions. Even if the surgery has been commonly done to treat your particular condition for decades, it could still be considered "experimental".

The more important indicator is whether or not Medicare covers it. In one case my benefits changed because Medicare decided in the middle of the calendar year that no more than 3 levels of facet injections were beneficial during a single visit. The day before they felt that up to 12 levels of facet injections in one visit could be beneficial. They didn't announce the change. Didn't say anything to patients or doctors, just started denying payment for anything more than 3 shots.

The state chapter of the AMA went up in arms & eventually my insurer (I don't want to give their name, but they're one of the major ones) agreed to send out letters to all in-network providers & to all insureds, and to cover all procedures performed prior to the date of that letter under the old rules.

The whole process is just mystifying. You also might try asking your doctor's billing office what codes were submitted & then call and ask to speak to the benefits/coverage department at your insurer. On occasion I've had better luck with them (usually they know less, but sometimes I've gotten lucky). Also, some insurance companies provide patient advocates. You can call your insurer & ask to be assigned a patient advocate (they may or may not have one). If they offer that service, you give the advocate permission to access all the same things your insurance company can access as well as to talk with your doctor to obtain information. They can't make decisions for you, but they can help straighten out confusion situations & explain them in plain terms. On occasion some large employers have an in-house advocate -- a member of your company's own staff (usually in HR) whose job it is to help employees with benefits issues. If the insurance people can't assign you an advocate, try calling your HR department & ask if they have an advocate who can work with you to straighten things out.

Also, not sure if you had surgery at a surgicenter or an actual hospital. If it was at a hospital, almost every hospital has patient advocates. Some are better than others, but they're free so it's worth a try. Some are volunteers (often those are the best) and others are paid staff. If it was at a doctor's office or a surgicenter, you're probably not going to get any help from them.

Hang in there & keep fighting!
frances

Hang in there & keep fighting!
frances

fashiongirl
Regular Member


Date Joined Jun 2010
Total Posts : 27
   Posted 7/14/2010 8:10 PM (GMT -7)   
Aha! I have an answer and it all came down to codes! My doctor's office is notoriously inept. So I called and they have resubmitted and hopefully things will be fine. Thank you everyone for all your advice. You really are incredible!!! The good news in all of this is that...I'm off my cane! My synvisc shot has done wonders (despite my doctor saying it wouldn't) and the pain level is getting better. I'm trying to ween off vicodin now! So yay! good news finally. Thanks again!
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