After going through all the tests, being pre approved, having the surgery and had my first fill. Now after 3 months post op, my insurance says that the paperwork from the hospital wasn't filled out properly so they haved denied all proceedures! What the <%$*&!!

I have always checked in advance with my insurance and the care coordinator before proceedures to make sure that each process was approved and got confirmation and approvals.

Now, since the insurance company claims "We have previously requested additional information regarding the listed claims. The requested information was either not received, or received incomplete, within the 45 days specified under ERISA. As a result we have processed this claim with the information we have available to us and have determined that NO BENEFITS ARE PAYABLE." They then sent me 2 faxes - claims that I now owe!! One is for the surgery at $53,300.75 and another for my first fill at $1,520.73. Where am I supposed to get that???

I don't understand. I have an HMO, I went to my PCP to get the referral, Everything was approved in advance. How can they now say, "We will not pay" after the fact! If I knew they wouldn't pay in the beginning, I wouldn't have proceeded...but now that I have had the surgery what am I supposed to do??? My husband is afraid we will lose our house over this.

They say that an appeal can take up to 60 days.....what happens if I get turned over to collections before they make their decision! I have worked to hard to have great credit for this to blow up in my face. Even though I have lost over 36 pounds, I am wondering if this surgery wasn't the worst mistake I have ever made for myself and my family. I am afraid that I have put my family in a terrible financial crunch.

Anyone ever had this happen to them? Any suggestions? Any ideas???

My husband and I are devistated!!!!!! :confused2:

WOw, did you get anything in writing prior to the surgery stating that they preapproved this surgery? I mean you were under the impression that this was approved right? Who gave you that impression? Is there someone in his office that was in charge of the insurance? That is who I would talk to at least that is where I would start. Also those charges just seem so high. I would call the hospital and ask them to give enough time to straighten this out. I work in insurance billing and I know that the one thing that will keep these people off your back is communication. If you call THEM once a week with updates I am sure they will keep you out of collections. If worse comes to worse, you just make weekly payments. You can only do what you can do. I wish you the best.

Who was your Doctor? Because they are charging you a arm and a leg! I'm having my surgery on Wednesday in OC.

I hope someone on here will have some good advice for you! But, I don't think your going to lose you house...it might mess with your credit score if you don't workout some time of payment plan with them.

I truly wish you the best of luck!

I had my surgery at Cedar Sinai with Dr. Khalili. This is the only place that my PCP and insurance would allow me to go. The insurance company claims that Cedar Sinai didn't fill the paperwork out correctly or incompletely and as a result, they denied the claim. I have all my authorization approvals in writing and called for confirmation before each process. When I called my insurance company prior to surgery regarding if I was approved or not, they said that if Greater Newport Physicians approved then they would pay.

The company I work for has a 30 day turn around time for appeals. You receive a letter with the decision within 30 days and it includes the name and number of the processor. I know this is a heavy burden for you and your family right now so my prayers are with you. Always remember you have the right to appeal an appeal. But hopefully you won't have to worry about that.

I am going to call the care coordinators tomorrow in West Hollywood and see what happened with the paperwork, I will try to get their help in this situation. They are the ones who got me in this situation in the first place with their paperwork error. Then I will see about filing for an appeal and let them know that I don't agree with their decision.

I will keep you posted but will still appreciate any comments.

Ddem,

That is just sooooo wrong! You need to appeal this. There is no way the doctor would have done the surgery if the insurance wasn't approved. This has to be some kind of mistake. Don't get discouraged, just try and work through this and it should be fine in the end. I know this is easier said than done, but it just has to be a mistake somewhere. If they still deny it, then I would see an attorney. Good luck to you.

Edited August 3, 200818 yr by Barbiek

If you have to be cash pay now... they need to give you the cash pay price.... i havent heard of anyone paying more then 20,000 for surgery! I was self pay and i had a 1 night stay in the hospital and my total was $18,000.... 8,000 went to DR and 10,000 went to the hospital... they better work with you!!!

After going through all the tests, being pre approved, having the surgery and had my first fill. Now after 3 months post op, my insurance says that the paperwork from the hospital wasn't filled out properly so they haved denied all proceedures! What the <%$*&!!

I have always checked in advance with my insurance and the care coordinator before proceedures to make sure that each process was approved and got confirmation and approvals.

Now, since the insurance company claims "We have previously requested additional information regarding the listed claims. The requested information was either not received, or received incomplete, within the 45 days specified under ERISA. As a result we have processed this claim with the information we have available to us and have determined that NO BENEFITS ARE PAYABLE." They then sent me 2 faxes - claims that I now owe!! One is for the surgery at $53,300.75 and another for my first fill at $1,520.73. Where am I supposed to get that???

I don't understand. I have an HMO, I went to my PCP to get the referral, Everything was approved in advance. How can they now say, "We will not pay" after the fact! If I knew they wouldn't pay in the beginning, I wouldn't have proceeded...but now that I have had the surgery what am I supposed to do??? My husband is afraid we will lose our house over this.

They say that an appeal can take up to 60 days.....what happens if I get turned over to collections before they make their decision! I have worked to hard to have great credit for this to blow up in my face. Even though I have lost over 36 pounds, I am wondering if this surgery wasn't the worst mistake I have ever made for myself and my family. I am afraid that I have put my family in a terrible financial crunch.

Anyone ever had this happen to them? Any suggestions? Any ideas???

My husband and I are devistated!!!!!! :confused2:

Get a lawyer ASAP! protect yourself...

I am a billing manager in a hospital and they are not allowed to bill you for the procedure because they havent provided them with the requested info, its not legal to do so. Just call the billing manager at the hospital and talk to them, they will straighten it out. Have you received a bill from the hospital? Or just a denial showing the denied charges? Trust me, you are not responsible for this bill. Good luck and let us know how it turns out!!!

JeanMarie - thanks for the comforting words. I have put a call in and left a message with the care coodinators at Cedar Sinai, they are the ones who work with the insurance company as far as paperwork and approvals. I will also call them first thing tomorrow.

I have not received a bill from the hospital, just a notice from my insurance company along with faxed copies of the charges stating that I now owe the balances. The hospital has just sent statements showing what is pending with my insurance. I have had seven claims submitted to my insurance for this surgery, all the pre op appointments and even one followup after the surgery - all were paid except the two most expensive ones....the ones requiring outpatient care (the surgery and the fill afterwards).

I will call the hospital tomorrow when they open, if they cannot take care of this right away then I will file an appeal. If that doesn't clear it up...I don't know what I will do since you have to sign a form before surgery stating that you will not sue the hospital, you have to ge to litigation with their lawyers.

Also KND, what happens when I file an appeal?? Does anyone have sample letters of an appeal?? I want to make sure I do some homework before making my next step.

I was laid off of work while having this surgery, I have paid an exorbant amount of money to keep up my insurance over the past 3 months so that this surgery was covered by my insurance. Three people from my company had this surgery without any problems with insurance. One of those people was laid off the same day I was. I called Cobra before the surgery and they told me that as long as I keep up the insurance payments...it would be covered since it was the same policy, I was just self pay on insurance instead of the company paying it. The last thing I need right now....is this headache on top of worrying about employment!!

I appreciate all of your feedback, my first response to the letter was to come to my friends here on this website for advice. The support this site gives each of us is unmeasurable!!! I appreciate each and all of your replies. Thanks so much.

Jazma - when you have the surgery...you sign a paper that states that that if this sort of thing arrises, you will not sue the hospital. I am sure you signed a simular one if you had the surgery because if you don't sign this paper, you will not be granted the surgery. Is this not true? In it you state that you will not sue the hospital and that you will go through litiagation with thier lawyers....who do you think will win? :teeth_smile:

My Meshelle - this is off the subject, but being banded in Vegas, do you have to go all the way back to Vegas for your fills? How far is that drive for you?

If you are unable to get the hospital working on this tomorrow then I would take matters into my own hands. Go up there and get detailed copies of your bills that have not been paid. Also get your medical records. Call your insurance and get someone on the phone who can tell you what is missing and ask them how you can get the information to them. Include all the prior auth numbers that you have. In the mean time talk to the hospital, set up some type of payment arrangements. Make them aware that according to the insurance them not getting a payment is thier fault and you working to help them. Hang in there. I know that this is a struggle but you can do this!

This is BS! :biggrin:

The hospital should be fighting this not you. I would personally go to the coordinators office and not deal with this on the phone. Go over everything with them. They receive other letters from the insurance company that you never see so they know exactly what additional information the insurance company is looking for i.e. surgical reports. I would also consult an attorney about this too and contact the state health insurance here's a link I found for you Health Care Services - Health Insurance - State of California

I would report this situation to them. They need to be your advocate for this. It's a breach of the contract the insurance company has with your hospital and other providers they are not paying.

This is intimidation and harrassment from the insurance company. They are not getting what they want from the hospital or anyone else they asked for information so why not go after you. They know that you will not accept this lying down and that you will make sure they get what they are looking for.

Also, make sure that you contact everyone that you could possibly get a bill from notifying them upfront what's going on. Their billing coordinators should be able to work with you and not send you to collections. Note the date, time, and who you spoke to and what the outcome was i.e. they will make note in their computers. We did that at the doctors office I worked at so we would know why the patients bills were outstanding and at the same time our office would continually contact the insurance company to get the matter resolved.

You should not have to do this alone I know that you will be doing most of the leg work to get this resolved but also make them work for their money too. Do not make any payments or payment arrangements to anyone just yet. You should only pay the patient's responsibility portion of it and nothing more.

I am so sorry to hear this. It's not right but things never are in the insurance field. The only thing I can tell you is to keep copies of everything and names, dates, and times of the people at the hospital and ins co. you talk to. Depending on your ins co. you don't have to have a certain paper for an appeal. You just need all the facts and copies of everything!!! Copy and date them and even send them cert. mail so someone has to sign for it. Send that to them and it can take 30 days. And it really may not be the ins co, it could be that the hospital or Dr office failed to submit the doc's correctly. You need to know from the ins co what doc they are missing,if its a ICD code or did the hospital fail to pre auth, all these things can be done again with no problem. They just have to decide who made the mistake and correct it. Hospital billing offices are well aware of insurance related issues,you just keep them informed and let them know you are waiting on it. Since you were approved prior to surgery it is most likely paperwork that needs to be corrected. You have a one up since you have all the pre-approval doc's. DON'T LOSE THOSE, it's your word against them but if they pre-approved based on the hospital finishing some paperwork you need to know. Call the insurance company and talk directly to a claims mgr, don't take no, and don't talk to a sup, you want a mgr, sups can't do a lot. You want to know what the hospital failed to send in so YOU can get it corrected. Then you contact the hospital and same thing you talk to a mgr not billing, because it may be ICD codes that need corrected. These claims and pre-approvals go thru a lot of hands so anybody could have made the mistake but since the ins co approved it, they should eat it, if it should not have been approved. Hope this helps.