What can you do if your health insurance denies a claim after you've had an operation?

Question

and initially you were told that they would cover you almost in full. (i got a bill for 17 thousand dollars) for an operation I had that my doctor's secretary told me would be covered 90% by insurance.

Answer 1

Take it up with the doctor's secretary. Nice of her to speak for the insurance company.

What the secretary says doesn't bind the insurer to anything. In the meantime, appeal the claim. Can't get any worse.

Answer 2

What is not noted is whether a pre-determination/certification was made. This actually done by the doctors office. They don't want to NOT get paid. The presumption is that due to the secretary saying this that a pre-cert. was done. But we can not go by presumptions now.

Call the doctors office and ask for the 'pre-certification' number given by the insurance company to them to verify a call was made to insurer.

If there is no pre-cert number given find out why. (This is ultimately your responsiblity so don't get too upset) While on phone with the office find out if they have the EOB showing denial and ask them what they can do to assist you. They could file the appeal for you but that is not standard within doctors offices like it is in hospitals.

You then may have to simply request an appeal to the Utilization review board of your insurance company. Find out if it was because of no pre-cert or other reason. Be prepared to get medical records of necessity etc.

But don't despair! The appeals process is generally handled quickly and efficiently by most insurance carriers. More than 80% of claims denied that go through appeals process CORRECTLY are paid very quickly.

Answer 3

Even if you were the one who called the insurance company, ALL of them have this disclaimer: "Quote of benefits is not a guarantee of payment. Actual benefits are determined when a claim is recieved" Meaning, they can TELL you anything, but can DO something else.

Call your insurance company and find out the EXACT reason for the denial - could be they did it in error, or a portion of it wasn't authorized in advance (in that case, it's not your problem. Someone at the provider's office or the hospital dropped the ball, and they have to fix it or eat it. ), or some portion of it was out of network - in which case you have to appeal it.

Answer 4

Ask the insurance company for a ruling in writing,then consult an attorney. Save any related documents. You may ultimately be responsible for the debt unless you can prove some sort of fraud on the part of the Dr. This could drag out for years and wreck your chances for credit if you are not proactive on getting this cleared up.

Answer 5

You can appeal the denial. Many times it will be authorized, if you just have the medical provider submit the proper documentation.

Answer 6

Appeal the claim...
 

Answer 7

When you don’t have money to get the care you need, here are some free resources for you, read through them, and pick up the phone, and get your needed help.
http://www.nlm.nih.gov/medlineplus/financialassistance.html
http://ask.hrsa.gov/pc/
http://www.omhrc.gov/templates/browse.aspx?lvl=2&lvlID=18
http://www.hrsa.gov/help/default.htm
http://www.thefrugallife.com/medicalalternative.html
http://www.google.com/search?q=Free+Low+Cost+Medical+Health+Services+&hl=en&client=firefox-a&rls=org.mozilla:en-US:official&start=10&sa=N

Free and low cost prescription medication:
http://www.xubex.com/
https://www.pparx.org/Intro.php
http://www.nami.org/Template.cfm?section=about_medications&Template=/ContentManagement/contentDisplay.cfm&ContentID=19169
http://www.themedicineprogram.com/links.html

http://www.cancer.gov/cancertopics/factsheet/support/financial-assistance

Financial Assistance and Other Resources for People With Cancer:Cancer imposes heavy economic burdens on both patients and their families. For many people, a portion of medical expenses is paid by their health insurance plan. For individuals who do not have health insurance or who need financial assistance to cover health care costs, resources are available, including Government-sponsored programs and services supported by nonprofit organizations. Cancer patients and their families should discuss any concerns they may have about health care costs with their physician, medical social worker, or the business office of their hospital or clinic.


This is about FREE hospitalization, if you need it and they WILL help you!
http://www.hrsa.gov/hillburton/default.htm
Hill Burton Hotline
1-800-638-0742
(1-800-492-0359 in Maryland)
In 1946, Congress passed a law that gave hospitals, nursing homes and other health facilities grants and loans for construction and modernization. In return, they agreed to provide a reasonable volume of services to persons unable to pay and to make their services available to all persons residing in the facility’s area. The program stopped providing funds in 1997, but about 300 health care facilities nationwide are still obligated to provide free or reduced-cost care.
http://www.hrsa.gov/help/default.htm
Medicaid is for people under 65, medicare is for the seniors.
How to apply for Medicaid or medicare
http://www.cms.hhs.gov/MedicaidEligibility/
http://www.aarp.org/money/lowincomehelp/applying_for_medicaid.html

For information about Social Security, Medicare, and disability benefits, call the Social Security Administration at 800-772-1213.
http://www.ssa.gov/

For information about Medicaid, contact your local social service or welfare office. You can also find information about Medicare and Medicaid at www.CMS.gov

How To Pay for Mental Health Services
http://mentalhealth.samhsa.gov/publications/allpubs/KEN98-0050/default.asp
http://depression.about.com/cs/findadoc/a/freelowcosttx.htm
Additional Public Benefits for Families Raising Children: http://www.nlm.nih.gov/medlineplus/financialassistance.html
DENTAL HELP:
Free or low cost dental care United States
http://www.nidcr.nih.gov/NR/rdonlyres/53F91091-23DB-47F3-8782-6572C33F9D42/0/LowCostFactsheet.pdf
http://www.raconline.org/info_guides/dental/dentalfaq.php
FREE AND LOW COST DENTAL HELP FOR DENTURES , BROKEN TEETH , PAIN , ETC.
http://dental-assistance.app-sl-1.aidpage.com/dental-assistance/

Need eyeglasses or eye care?
http://www.nei.nih.gov/health/financialaid.asp
http://www.uniteforsight.org/freeclinics.php

Free Mammogram:
http://www.cdc.gov/cancer/nbccedp/
How to Get a Free or Low Cost Pap Smear, The National Breast and Cervical Cancer Early Detection Program provides free or low cost Pap smears to eligible women across the country. Through this program, uninsured and impoverished women can receive Pap smears at local clinics and doctor's offices.
Here’s a list for every state:
http://cancer.about.com/od/screeninganddiagnosis/a/freepapsmear.htm

Where can I go to get free or reduced-cost prenatal care?
You can call this number if you need free birth control help, too!
Women in every state can get help to pay for medical care during their pregnancies. This prenatal care can help you have a healthy baby. Every state in the United States has a program to help. Programs give medical care, information, advice and other services important for a healthy pregnancy.
To find out about the program in your state:
· Call 1-800-311-BABY (1-800-311-2229) This toll-free telephone number will connect you to the Health Department in your area code
· For information in Spanish, call 1-800-504-7081
· Call or contact your local Health Department.