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peace_of_mind

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I know that this posting does not belong here but I need somebody to give me an idea to search

Recently my daughter had a surgery in Childrens Hospital Los Angeles. The hospital took a oral authorization from the insurance company and did not take authorization in writing. Insurance is denying to pay. Hospital authorities are not releasing copies of the documents they sent for claim from insurance. They are giving me only a reference number that does not tell me what exactly they are claiming from the insurance. I think I need a legal advice.

What kind of attorney should I search for? Please help.
 
try Better Business Bureau:
http://complaints.bbb.org/Welcome.asp

*they can suggest a lawyer;
 
Try calling your insurance company

Give the reference number to the insurance company and they should be able to provide you the claim information. I think you are entitled to get the claim information. Who is your health insurance provider? Mine insurance provider always send me all the claim information approved or denied. I think you should talk to insurance company.
 
Here is something that I think you should be aware of, that is:

There are two types of treatments allowed by Insurance companies one that does not require any pre approval and second that needs pre approval.

Insurance companies usually reserve right to decline any payment for a treatment that is not covered under policy or for which the pre approval was not sought or if some non standard procedure was performed for a treatment. This is done to prevent insurance fraud and to ensure that no luxury procedures like cosmetic surgery are claimed for as usually these are not covered.

Having said that one should evaluate the insurance policy very carefully before getting any medical procedure done.

While I don't know the complete background of your case but based on what is stated in your posting, I'm trying to comment. As you mentioned that the doctor / hospital had taken a verbal approval over phone then the insurance company should not have any problems paying for the claims.

The denial in such situations when insurance companies initially agreed to pay can be challenged in court. The court can seek the tape recordings of the conversation between the hospital staff and insurance company rep for pre approval. Also the treatment records from hospital could be sought. This could force insurance company to settle the claim in your favor. In case the appropriate approval was not taken by hospital then at times hospitals end up offering a discounted rate for procedures.

But, going to court should be taken as last option, as such cases could be very time consuming and painstaking. It would be better to speak to Insurance Company and try to resolve the matter. At times the person on insurance hotline is either not very knowledgeable or not very cooperative in such cases call back again. I have experienced that sometimes one rep would turn down the request but other would gladly accept and help. But before one calls insurance company he should be fully aware of provisions in the policy and know that whatever he's asking for is covered or not. Also, the correct approval procedure was followed or not.

Sometimes it is also a good idea to involve employer's benefits manager to speak with the insurance company and resolve the issue.

Please do not take above comments as an expert advises, as I’m not an insurance expert or a lawyer. Please seek an expert’s advise for better understanding to tackle this situation.
 
gatos, noknurd, thukralrk,
Thanks for posting replies.

I have talked to the insurance company several times. I did not find a solution. I was seeking help and suggestions.

thukralrk:
I forgot about the conversations being recorded, thanks for mentioning...,
 
Once I had a dispute over some claims with my insurance company. I wrote them a letter and stated my telephonic conversation in the similar situation with their rep and quoted the rep's answers. I received a response from the insurance company detailing the conversation between me and their rep word to word and explaining what is meant by what.

It was a pretty convincing letter but, there was a shortcoming that they did not refer to what was said in the orientation program. So I wrote back knowing nothing would happen but, I received a letter back stating that those provisions are not as per my policy and either the orientation personnel wrongly quoted or I misunderstood the provisions. However, they'll try to get some discount from Hospital. I paid all the dues to hospital upfront with an expectation that once insurance company negotiate some discount then I'll get the money back. It did not happen.

Anyway the point I'm trying to make here is that it might be a good idea to write to insurance company giving reference of doctor / hospital's conversation with their rep. In such a situation insurance company should reply to you with the details of the conversation and you'll be in a better position to judge who is at fault, insurance company or hospital. In case hospital is at fault then you can fall back on the hospital to demand discount for their failure to apprise you upfront for the pre approval status.

As per my experience it is very difficult to make insurance company pay for something that is not covered in the policy or non standard procedure was done or appropriate pre approval was not sought. But, there is no harm in trying.

These are just my thoughts.
 
If all else fails, try negotiating

with the hospital. Firstly, start with telling them to pay the whole amount by reminding them that it was their fault that they did not take a written authorization (I am assuming that they are not denying that they got some sort of authorization from the insurer) and therefore they should pay for it, not you). Also, if possible try to somehow get them to document this on paper (for example by sending them a letter stating that person X had taken a verbal authorization on date D, and that person Y had confirmed it to you).

Then offer to pay 30-40% of the uncovered portion (assuming that the insurance company does end up paying something) and work your way upwards slowly.

I would be surprised if they do not settle for 45-50%. The cost of collection for health care providers is very high and in most cases they are willing to settle for the principal that a bird in hand is worth two in the bush.
 
Without knowing the background of the case, if you feel that your claim has not been settled properly, you can always dispute the claim through the department of health or insurance, I am not sure exactly what it is called. It should be at the back of your claim form. Atleast I know for sure, this provision is applicable in IL. I did this once, I just told the insurance company, I am going to do that and I got the money. It was a very small amount (something like $85 for medicines), so they may have thought why go through this dispute process and let's just settle it. It's just an idea, it may or may not work for you.
 
Thanks guys
Let me give some details:

My employing company is in MI and I live in CA. I have PPO plan from the employer (both medical and Dental).
My daughter 2000 born premie with heart defect. Corrected in 2001 at age 1 yr. Under wieght by 30 percentile at age 2yr. Ascertained Risk of low weight and low immunity. Suggested High calorie Milk (like Pedia Sure) and fat foods like Ice cream, candys etc so as to put on weight quickly. Instructions, do not let the child cry or make her chew for a long time, so cant waste energy. Un-noticingly the child developed dental problems. The surgery was dental procedure.
Under California Law, any child under 7 with moderate risk, the hospitalization charges would be considered as medical necessity. (I dont remember the chapter number exactly under CA law. I have the the documents at home).
The insurance is denying, saying under MI law there is no such chapter to follow. I am not able to find an equivalent law under MI.
Also I have a question, when I have a PPO plan, I can go to any doctor/surgon/hospital under the network, howcome the State comes into picture? Insurance company did not answer this question.
I did a lot of homework before the surgery. I searched for the surgon/anesthesiologist/cardiologist and hospital (every body) to be under the network.
I am in search of a magic person who could understand me and bring the insurance and hospital auhorities on to one table.
 
peace_of_mind

This is a multi billion dollar industry and there are professional attorneys who specialize in this.

Now there could be a pre-approval for hospital admission which does not necessarily mean a pre-approval for a surgery and your insurance company could very easily argue on that. However, since you are a CA resident your insurance company has to follow the local laws of CA when it comes to your treatment. If you think you have a valid claim, call them several times, send them certified mails with some proof from hospital.

But, if you have not already paid to Hospital, do NOT pay them yet. Put a legal dispute on this claim and they cannot even touch you. I know it is going to be a long battle, but if you hire a good lawyer, you may win in the end. But, if you pay them now, then you have already lost the battle. Once you have a dispute on the claim they cannot involve any collection agencies.

I know how frustrating this is and good luck with your settlement.
 
Hi peace_of_mind,

Do not worry. Here is what i think you can do. Certanly insurance will pay the following becuase they are part of any PPO plan for a surgety

1. Anestesia
2. exp for anestial doctor
3. hospital bed/other hospital exp like nurse etc
4. general surgen exp

the only part which you will not get covered is your DENTAL doctor procedure exprense.This dental doctor expense might turn out to be aroung 1500 to 2500$, is what you will have to pay finally. Just ask insuracnce to pay for the remining like anestesia etc.. hope this helps. talk to the insurance in this way saying that fine you do not have to pay for the dental doctor expe but please pay atleast the remaing covered expenses like anestial and hospital charges etc. this could work. if they say no send in a written request. if every thing fails talk to the hospital they will normally give a monthly plan without interest to pay the balance.

regards
 
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