Question about medical insurance?

Question

I had an inpatient laparoscopic nissen fundoplication January 5th, with one day hospital stay. Prior to the decision to have surgery, I had motility studies done and an endoscopic exam. The motility study showed that I had low pressure, the endoscopic exam showed that I had esphagitis. Anyway, the doctor that did the motility study and the surgeon decided that I should get a lap nissen fundop. After I met with the surgeon he set up the time. Well, anyway, I got this letter from my insurance company stating that the hospital never obtained prior authorization before the surgery per their contract, and that I may not be responsible for the bill. They denied the insurance claim and said that the hospital can appeal. However, they wouldn't have paid it anyway, because the surgery could have been performed as an outpatient surgery. (They did however pay for the surgery itself, they just refused to pay the hospital stay) Do I owe the $16,000 + hospital bill?

BTW, the letter was addressed to the hospital, and I received a copy of it.

Answer 1

No. You said it yourself, you are not responsible. The hospital is required to obtain their own authorization. Don't sweat it unless you get a bill from the hospital. the insurance will probably pay for the hospital service, up to the overall outpatient rate, after the hospital explains why they did what they did... Bottom line, you don't owe it.

Answer 2

Unless you can find a loophole, you are probably responsible for the bill. The insurance company might automatically reject certain claims to keep their profits up, so it might be you have to appeal. If you have financial hardship, you can write letters to the hospital, surgeons, radiologists, etc. and ask if they can offer any assistance (lower their portion of the bill, set up a payment plan, etc.).

I feel your pain. The last surgery I had left me with about $50,000 in unpaid medical bills from all the tests, specialists, medications prior to the surgery and then the surgery and hospital stay.

Sometimes I wonder if it is better not to have insurance since there is more aid available to those without insurance when it comes to large hospital bills.

Answer 3

If you did what you were supposed to - meaning, getting any necessary referrals and provided your insurance information before the surgery, and the hospital dropped the ball by not doing their portion of obtaining the authorization, you're not on the hook for the bill. They screwed up, they need to eat it. It is also their responsibilty to appeal it. It's not a secret that insurances need authorization for certain things, and if a provider is unsure, it's their responsibilty to check beforehand.

However, what you can do is call your insurance company and ask them for the specific reason for the denial and if there's anything you need to do as far as appealing. (Make sure you get the name - first and last inital - of the person you spoke to.) If they say you can send a letter - do it. Just to cover your backside. If they tell you it's up to the provider (hospital) to appeal - call the hospital and speak to the billing department and tell them you received this letter and you tried to appeal it yourself and the insurance told you the appeal has to come from the hospital. (Again, make sure you get the name of the person you speak to.)

Answer 4

contact your state's department of insurance for advice or, an attorney who specializes in consumer law. the fact that your insurance company's preferred procedure for pre-authorization wasn't followed does not automatically release them from responsibility for the bill. this can be a nightmare if you don't take immediate action so, follow up and make as much noise as possible until that bill is settled.

you may also contact your human services department to see if you can qualify for social services for that month. i had a friend who had inadequate insurance and the state picked up her bill after a long hospital stay.

Answer 5

Okay, it sounds like you were under the care of an HMO. You need to call your insurance company and find out as much info from them as possible about what proper procedure should have been and definately contact a lawyer.

If the doctor did not follow his orders under a closed panel HMO I dont belive you should be responsible but it may secretly be attached to your credit so be careful.