So the first thing I did was call my insurance (humana) last fall to find our what my coverage for surgery was. They told me its covered at 90/10 as long as you meet the criteria. Lady sends me a info sheet. I meet the criteria. I make my appt, go through all the steps. MD office submitted for pre-approval and I was approved within days. Had my surgery in January. Now am looking at claims online and finding most of them are denied. Called Humana...oh well, there is a MAX OF 10K lifetime for obesity coverage!! What?? This is the first I have heard of it. Called hospital billing and they will discount a certain portion for being cash pay, but still will owe around 30k. I feel like a total idiot here for not going over this with a fine tooth comb. Maybe I am expecting too much from my doctor's office, but I certainly thought they would have mentioned this to me when they submitted for approval. I am just beside myself. And certainly I should have been told when I called Humana. Husband looked it up and it is in the fine print of our policy. I am just so upset. Trying to look on the bright side and look at this as a huge investment in my future, but 30K??! Thanks for letting me vent.

So if it is a max $10K OOP, why don't you just have to pay the $10K and they cover the rest since the procedure was approved?

@@number1rudegal you really need to submit an appeal and do it in writing and cc the state insurance commissioner. If nothing else the cc to the IC will make sure Humana crosses all their T's and dots their I's....@@losergrl75 is spot on. The customer service reps copy and paste the information from their instructions into their comments. you need to be adamant that you were not told of this limitation prior to surgery......Also, is your provider in-network? How much did Humana allow? Usually the provider bills a certain amount, then the insurance allows a much smaller amount and then pays what ever their percentage is.....like 80% or whatever your contract says.....and you would only be responsible for the difference in the allowed amount and the amount Humana paid.....not what the provider billed. In your case is that were the 30k is coming from? That seems like an extremely high allowed amount. Good luck.

Request for the call to be pulled.

The call was most likely recorded. Max $10k OOP would mean that's the most you would pay - not the most the insurance would pay! Fight this! The Surgeon's office wouldn't have let this go thru if they knew about it and it should have been included with the prior authorization they received. Is this insurance through an employer? If so - they should have someone who can help you.

So if it is a max $10K OOP, why don't you just have to pay the $10K and they cover the rest since the procedure was approved?

Its the other way around I think thats the problem.

If it's the other way around then that means your max insurance coverage is $10,000, which means it's a pretty sucky policy. OOP is what you have to pay before the insurance kicks in.

For example, I have a $3000 deductible and $6000 max out of pocket. Which means I have to pay 100% of all medical expenses up to $3000. After that, insurance pays 80% and I continue to pay 20% until I have paid a total of $6000. After that insurance pays 100% up to my annual limit which is a couple million.

Edit....

You're right, I just reread the original post and it is $10K Max coverage for obesity charges, which is different than OOP Max.

It seems strange that the hospital didn't make the OP pay in advance or at least make payment arrangements with them. I thought that all hospitals did for elective procedures.

Fight it, fight it, fight it.

I had a horrible experience trying to get a knee surgery approved that the insurance company said was investigational and experimental. If I could figure out a way to make money at it, I'd start a business helping people fight insurance companies.

Step 1 - find out if your insurance is a "regular" insurance that your employer buys, or if your employer has "self insured" and pays the insurance company to manage it. The reason this is important is because if you have "regular" insurance, then you have a much better chance of fighting it with your state insurance board. If your company has "self insured" then the state board has no jurisdiction, and you have to look at the federal ERISA laws to govern your policy.

I agree with the other posters who say get the recording pulled. You need to know exactly what they told you and what they didn't.

Pull every EOB from your insurance (they should be accessible through the website) and get a detailed billing from every doctor, lab, hospital, anesthesiologist, etc. that you used. You will need to reconcile these against each other. Also ask your doctor's office for copies of any documentation they have about their conversations with insurance.

My experience involved 4 sets of appeals, where I sent over 300 pages of documentation and exhibits about peer reviewed studies and protocols. After I found out that they had sent me down the wrong levels of appeals, I started quoting chapter and verse of the federal regulations and laws they had violated, and then all of a sudden my surgery got approved. Then a glitch in their system caused a $10,000 payment to just disappear... took me 2 weeks post-op while I'm doped to the gills to reconcile everything and get a 3rd level supervisor on the phone to review my reconciliation with her system up to find the computer glitch that caused the problem, and get it fixed.

It's not easy to win with the insurance companies, but it is possible.

Best of luck to you!!!