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:

I also work in a hospital. DO NOT and I mean DO NOT give them any type of payment or set up a payment plan without first talking to an attorney. Once you give them the first dollar and I mean that literally you have just accepted that bill as legitimate and you now owe it. Keep fighting, you do not owe this bill if you were indeed preapproved. If the fight becomes lengthy send letters to the three big credit gods and outline the issue. And I will say it one more time - GET AN LAWYER, if you think you can't afford one look at the amount you may pay if you don't

I work in HR/Benefits and see this sort of crap all the time. Sounds like they asked for additional information from one of the providers but didn't get it. So they just gave up and denised the claim. What I would do is give them a call and ask EXACTLY what is needed. Document the call, name etc. Also go online and see if you can get copies of your EOBs. I am sure since it was pre-approved it was fine, someonen just didn't do their job along the way.

Good luck!

I work in HR/Benefits and see this sort of crap all the time. Sounds like they asked for additional information from one of the providers but didn't get it. So they just gave up and denised the claim. What I would do is give them a call and ask EXACTLY what is needed. Document the call, name etc. Also go online and see if you can get copies of your EOBs. I am sure since it was pre-approved it was fine, someonen just didn't do their job along the way.

Good luck!

I agree. It sounds like a paperwork issue. In addition, also document date and time of call. Document this information for each and every call you make. When you make the first call to your insurance company, find out EXACTLY what and from whom they require the info. If they try to give you the run around be firm. Insist on the info and write down everything they say, repeat it back to them to make sure you have understood what they want and have them confirm that that is all they need to proceed. If you don't get what you need, ask for a supervisor and or that the call be recorded. Call the medical provider and tell them they will not receive payment until this additional paperwork is done and you would like a copy of whatever they send to the insurance company for your records. If you think it would help, offer to pick it up and fax it to your insurance company to assist them. They will likely want to handle it themselves, but whatever it takes to get them moving!

Stay on top of everyone until it is paid. It is unfortunate that you have to deal with this, but I think with a little persistance, you will get it taken care of quicker than anyone else. Once it is behind you, it will just have been a minor irritation.

Good luck.

The insurance company has a duty to pay or deny a claim within a certain amount of time, otherwise, they can get in trouble. If they don't have all the information they need to pay the claim, they have to deny it. It isn't really a denial, they will re-open the claim and pay it when they receive the requested documentation from the hospital.

Everything that people have said here is true. DON'T set up a payment schedule. DO find out what is missing and contact the appropriate people to get that submitted. DON'T panic.

In California, HMO arrangements are between the insurance company and the provider. The provider is not allowed to bill you anything more that your copay unless they have provided a non-covered service. As long as you have the pre-authorization paperwork, and you still have the insurance, you should be fine.

Remember - you did not get a bill for $54,000...you got a notice from the insurance company saying that they didn't get all the required paperwork. If it was a bill, it would have come from the hospital.

This is just an annoyance...it will be fine.

Where did you have your surgery that the cost was that high???? You can get this surgery for less than $15000. And, it sounds like the hospital dropped the ball, so I would get them back involved and make them submit the paperwork they were supposed to. The insurance won't send you to collection in 60 days. They want the hospital to pay and send you those notices to make sure you light a fire under the hospital. Make them go to work for you. They haven't been paid either, so it is in their interest to make things happen.

I am sure you can get this issue resolved with suggestions provided above. Definitely don't make payments or setup a payment plan at this point. Also, don't stop making follow-up calls daily until it gets resolved. The squeaky wheel gets the grease and this is a very important matter for you and your family.

If you are diligent, this should be able to be resolved quickly. I am sorry you have to deal with this on top of being laid off and major surgery.

Go with the above suggestions. DO NOT pay any money to the hospital - the bill did not come from them but it will if you start paying them anything. Consider an insurance attorney if you don't start getting answers fast. I believe the paper you signed is worthless to the hospital if there was negligence involved. If they are negligent they can be held responsible. It is to their advantage to get this straightened out.

Your state has an office that monitors insurance issues, as well as a state's attorney office. They may be interested to hear what is happening to you. Most hospitals/insurance companies do not like hearing from those people. (kinda like the IRS)

Don't panic. This will get worked out...

I got two denials from the insurance company before I actually got approved. Once they received the missing paperwork it was an immediate approval. I am sure that this will get resolved. Talk to the person at the surgeon's office who submitted your paperwork first and see what they know about this. They should be able to talk to your insurance and see what they are missing and fax it in for you.

I wanted to take a moment and post an update on this issue with the insurance and the hospital.

It took alot of phone calls and fighting on my part but this issue did get resolved. The problem was due to two issues - 1. the coodinators failure to give the insurance company the approval number that they recieved before surgery...(this was the only thing holding up payment of the fill...why didn't she follow through and save me a huge headache!!) - 2. The insurance company refused to pay the 53,000. for the operation due to the hospital records department failure to send over my medical records when the insurance department requested it. I called numerous times to the hospital records department and was frustrated by the "I don't care attitude" and the "Well, I don't know what to tell you" comments. I told her that I knew what to tell her....she wasn't getting paid without those records cause I wasn't going to pay for her inability to do her job! The lady in records said that if I paid her an additional $25.00 for what it cost in paper to send those records...she would send them to me and I can do whatever I feel like with them. I told her that this was part of the process that my insurance was already paying and that I would esculate this issue if I needed to. Within an hour of my last call, the insurance company got the information they requested and the claim was marked paid!

It is hard to understand why we have to get involved in the process that they are paid to do but the fact is, we do. My advice is to keep all your paperwork, get names of the people and departments that you are talking to for reference because you WILL need those to refer to if you want to get anywhere with the different departments you will be calling. And last, keep working on it! Don't give up, I got plenty of "I don't know what to tell you, I cannot help you" but I persisted til I found someone who could help and I got the answer that I needed.

Now, my claims are paid and I have had my 3rd fill. Since going through all of this, I had no trouble at all with the paperwork on my last fill....seems the coodinators were on top of it this time and the claim was ok'ed and paid on the first try without my intervention.

So all is well and I am down over 40 lbs and still counting. Good luck to the rest of you!! Happy Losing!

I'm so glad to hear this worked out for you. You should not have had to go through all this, but you did a great job. Congratulations.

And - congratulations on your weight loss. You are doing great!

Thought that I would follow up on this and add what has happened over the last 8 months. I stuggled to get the care providers to get the proper paperwork to the insurance company but finally got it taken care of. BUT, every month since then - with every fill/adjustment - I have to do it all over again. It is a constant struggle to get the girls who fill out the paperwork to do their job. I always have to get involved to get it done...because they bill me $4000.00 per fill until I make them take the time to get the proper codes and discription to the insurance company. What a pain - I have just stopped going. I have had three fills as of last October and got so tired of going thru this, I have never gone back. I am soooo done with them. Now I have to find another doctor to do my fills, preferrably around Orange County.

WOW! $4000 for a fill??? Ddem, you would be ahead of the game if you flew to somewhere outside your area for fills and threw a little vacation in at the same time! That is only $1000 less than my surgeon charged for my SURGERY! I'm not sure what she charges for fills, as my ins is paying for them and I have not received the paperwork yet, but I think it is in the $200-$250 range.

That is a lot of money for 15 minutes of time and the expertise of sticking a needle in a port.

JoannMarie - That is what they try to charge me, but when the insurance company negotiates with them, the fill is only $1200.00. but still alot of money to pay for a fill. My share of it after insurance is about $90.00 - that is- if they ever get it billed right!

It can be so frustrating to work with the billing people AND the insurance people. The trick is finding someone who cares whether your problem is solved or not... I hope you find your sweet spot soon - it will save a lot of frustration for you.