reasonable and customary insurance?

Question

I have group insurance, but before I had surgery no one told me that this (only hospital around that could do this surgery) was a not participating hospital. (some of the doctors are participating). I was approved for surgery, but was not informed of the non participation, is there anything I can do about this?

Answer 1

Unfortunately, under a PPO or POS-type policy, it is the insured's responsibility to ensure that care is rendered in a participating hospital. In the event the insured choses to use a non-participating hospital, a higher level of financial responsibility will be incurred.

I've reviewed a great number of these types of contracts and have never seen a clause that gives an exception for a case such as this. However, that's not to say it doesn't exist. Sit down with your certificate of insurance and go through it very thoroughly to see if there's any language that will work in your favor. If you find anything that seems favorable to you, send the insurer a written appeal, asking it to reconsider. You may also contact your state's insurance commissioner's office to discuss this situation. An investigator will be able to tell you whether your state has any laws pertaining to this matter. However, all insurance commissioner's offices carefully review policies before they're issued in that state to ensure they comply with the laws, so it's unlikely this policy is non-compliant if it's fully insured.

The fact that your insurer approved the surgery doesn't mean it's agreed to cover 100% of the costs -- all the approval means is that the insurer agrees the surgery is medically necessary. Reimbursement of claims is a separate issue from the approval of services.

It would have been helpful to you if the hospital had informed you that it's non-participating, but then you would have been stuck having to travel to another hospital. I'm not sure the hospital has any liability because, again, it's the insured's responsibility to ensure a hospital's participation status.

I'm sorry I couldn't give you better news. Let me know if you have further questions.

Answer 2

I'm not sure if there is anything that you can do. It is typically the patient's responsibility to ensure that the medical providers and/or facilities participate in the patient's health insurance plan.

I've heard of similar situations where a hospital is a participating provider, but some of the individual physicians are not. When you're in the hospital, you are usually seen by any number of physicians. It's really important to make sure they accept your health insurance, otherwise you could be on the hook with the physician.

You might also want to check with your insurance company to see if they have different co-pays and deductibles for out-of-network or non-participating physicians. The co-pay will probably be higher, and you may have to fulfill a deductible before insurance will even kick in, but that's better than having to foot the whole bill yourself.

Hope this information helps -- good luck!

Answer 3

The burden is on YOU to be sure that the providers are participating.

Having said that, most of the time if the procedure is done by a participating physician, the insurance company will note the file and cover the procedure as if the hospital was participating.

You should call the customer service number at the back of your insurance card, and just ask, " why is the doctor covered but not the hospital he operates at?" and they'll probably re-queue the invoice for payment.

Answer 4

You needed to get prior authorization to use a non-participating facility.
Had you contacted your insurer in advance they would have either approved your facility, or referred you to a participating facility.

You now need to file an appeal with your insurer...that is your right, but you must do so in writing and in a timely manner.

Make it clear to them that your doctor did not advise you that the hospital/facility he/she would perform the service was non-participating.

His/her office staff should have checked all of that out prior to rendering services to you!

Answer 5

Contact your insurance company and ask about their appeals process. If you can prove that this facilty was the only one (within a certain mile distance, some insurance companies it's 50 mile radius of patient's home) that performs this surgery, there's a very good chance it'll be approved - probably with some of it out of your pocket (like 30% or so)

Be warned, it isn't going to be an easy fight - insurance companies count on your getting frustrated and annoyed. Don't back down! Keep copies of everything you send to the insurance.

Good luck!!

Answer 6

you assert the medical institution common a negotiated value out of your insurence which that medical institution became not area of their community? in the event that they common a negotiated value, reasonable and costomary or not, they have then common a term with your insurence and additionally you're actually not responsible for billing rates over the negotiated value. in the experience that your insurence is only telling you that a charged volume became over "reasonable and everyday" however the medical institution isn't area of the community, the medical institution isn't required to shrink the expenses with the aid of that quantity and additionally you will possibly then be responsible for any volume over what your insurence has paid. the only way you would be helpful the medical institution common a negotiated value is to get that rfile out of your insurence company asserting the medical institution common the discounted value fee. If the medical institution is making an attempt to recieve fee from you over the agreed upon negotiated value, they are responsible as long as you have data of their recognition of this negotiated value.

Answer 7

It is your responsibility to ask if it is a participating hospital. Are in network hospitals in the area? If so, you are out of luck.

Answer 8

yes,,, fight fight fight.. if your saying you got the approval.. than the insurance must cover... the customary and usual... i have a chart of most.... these aren't guaranteed as the insurance companies bundle if more than one procedure is performed...