Can an HMO revoke somthing that they have already approved?

Question

Insurance company will not approve operations if they are deemed cosmetic only. My insurance company might have mistakenly approved a surgery for me because it did not have enough info to know if it was going to have any benefit besides cosmetic. Can they revoke their decision if they are informed by a third party that it might have been a mistake?

Answer 1

An insurer has the right to retroactively revoke its approval of a procedure if the initial decision was wrong and the incorrect decision was in direct conflict with their contract. In your case, hopefully the reversal happened before they did the procedure. The insurer has more leg to stand on if they catch this pre-procedure. I'd fight it more if you already had the procedure done and they were trying to get out of paying after the fact.

Your policy (contract) will spell out the terms of what is and isn't covered.

If there is a dispute over what it covered that is due to vagueness in the terms....the default in most states goes to coverage, rather than to denial....

If this is the case....vagueness in policy terms....you should first try to work it out with the insurer....and after you've exhausted your appeals with them....contact your state's insurance regulator...usually the State Department of Insurance.

Answer 2

Preapproval for services really doesn't mean anything. "Actual benefits are determined when a claim is received" - I have heard this statement so many times I say it with the insurance reps. Insurance companies can do basically whatever they want when they get the claim. Then, you have the right to appeal any decision you don't agree with. It's time consuming and often frustrating, but insurance companies count on that. (They hope you say "Screw this!" and pay the bill so they don't have to.)

(For example - and this is a little off-topic, but proves my point - I know of a case that when you call an HMO, they have the proper PCP listed for the patient, but when the doctor submits the claim, it's denied because that doctor isn't PCP. Meanwhile, when you appeal the claim - you win because the insurance company messed up. )

BUT - pre-approvals for things like surgery, because they're not cheap, are usually scrutinized closely - the insurance doesn't want to pay for anything they don't absolutely have to. The person approving or denying the preapproval is supposed to be a medical director, therefore, if they're not aware of what EXACTLY your surgery is, that's their mistake. Just make sure you have EVERYTHING related to the preapproval in writing - often the insurance company sends a letter stating it.

Answer 3

It depends on a number of things.
They can take back approval if there was a fraud or misrepresentation. If you or your doctor lied to say something was medically necessary when it was not, they can revoke the approval.

If they required more information about the surgery, they have the ability and right to request it before making a decision. However, once they make a decision, there are certain obligations that go with that. Unless it is specifically in the contract that they can revoke pre-approval of a procedure, they are now subject to legal estoppel, which means they are committed into it.

Answer 4

The definitive answer to your question lies within the insurance laws of your state. Contact your state's insurance commissioner's office for advice. All insurance commissioner's offices have investigators who will look into complaints such as yours. If your HMO is unlawfully denying the claims, it can be ordered to pay.

For example, in my state, an insurer cannot retract a preauthorization for any reason once it's given, so long as it's not been lied to. If the coverage is still in effect on the date of service, the carrier MUST pay, even if the service is excluded from coverage.

States without this type of statute can still rely upon the doctrines of "waiver and estoppel." While your insurance commissioner may be able to assist you with this (depending on various laws), this may be a matter you have to privately litigate.

Another issue that I think you should discuss with your insurance commissioner's office is the "third party" you've referenced. On what basis did this third party have the right to convey such information to your HMO? It is possible this third party violated your right to medical privacy, pursuant to the HIPAA Privacy Rules and any similar laws in your state. Here's a link to a brief summary of your rights:

http://www.hhs.gov/ocr/hipaa/consumer_summary.pdf

If you feel your medical privacy was violated, you can file a complaint. Here's information on how to do that:

http://www.hhs.gov/ocr/privacyhowtofile.htm

I hope this helps.

Answer 5

I do not know what state you live in, but I would find out what the address of the Insurance Commission Department is and file a written complaint. They will act on this and investigate. Usually you can find the address from the state capitol where the department of regulations are. I wish you the best of luck. Most of my career was dealing with insurance companies and how some rip off anyone! Best of luck.

Answer 6

What evidence you have that they didn't have enough information? Do you think your doctor might have made a mistake on the form? Unless you know what mistake and whose mistake, it's hard to tell what will happen. They may never find out. But again, they may find out and send you a bill, in which case you may be able to negotiate. The question is how likely you think they would be informed of the mistake or will find out on their own.

Answer 7

Have you read your CONTRACT with the HMO? This details your rights and duties and theirs as well. This should be the very first place that you look to find out whether or not this is within their rights. Secondly, the laws of your state are available online at the web portal of your States' Secretary of State Office and should be read to further understand your civil rights in this regard. Thirdly, as unconscionable provisions of a contract are not enforcable, it behooves you to consider a law suit if you still feel that your rights have been violated. Whether you bring suit yourself in person or through a lawyer is up to you. Nobody on Yahoo! Answers can answer this question without looking at your contract and reading over the law that is every citizens' duty to be personally familiar with.

Answer 8

Yes, but you can make them honor the original decision, if you have it in writing from them.