denied medical coverage?

Question

I am currently going for fetility treatment and was told by Dr. Office that I had coverage for pretesting.I checked a second time with billing and was told again that I had the coverage. Now I am being told that claims were denied and a mistake must have been made. Am I liable if Dr. office made a mistake?

Answer 1

You are responsible for the charges. Even if the dr's office was told by your insurance company over the phone that there was coverage for whatever you received, they also give a disclaimer that this is only the general benefit and no determination of benefit can be made until the bill is recieved and reviewed. Sorry, you did recieve the services. It might have been a good idea if you had checked with your insurance as well.

Answer 2

Technically, the doctor's office did NOT make a mistake. Every time you call an insurance company, you hear this disclaimer either on a recording or from an actual person: "Quote of benefits is not a guarantee of payment. Actual benefits are determined when a claim is received." Meaning, your insurance company can TELL the doctor's office anything they want to hear, but the insurance can DO something completely different when they get the claim.

Your only recourse in this situation is to appeal thru your insurance company. Call member services and find out why your claims were denied. If it's for any other reason other than "timely filing" (meaning the doctor's office did nto adhere to the rules about filing claims, in which case, they have to eat it.) you next question is to ask for the appeals process - including a contact name, address, and phone number. As long as the services are a covered benefit under your plan, you can appeal. If they are not a covered benefit, there's nothing you can do to force the insurance to pay. In that case, you need to set up a payment plan with the provider. Regardless of who made the "mistake" you did receive the services rendered, and to not pay for them because you disagree is technically theft, and you can be sued for it.

Answer 3

You incurred the service so you are responsible for the charges. However, talk with the billing person at the dr office. Since they made a mistake, would they be willing to reduce the charges?

Or, had they told you the testing was not covered up front - would you still have had it? If so, suck it up and pay for it.

Answer 4

I'm sorry but you are responsible for the charges. It is your responsibility to know what coverage you have not your doctor's office. That is why they have the 1-800 number on the back of your card to ask questions. Most insurance don't cover fertility anyway.

Answer 5

Health insurance isn't my area of expertise, but I seem to remember that it is up to you to obtain prior authorization for all elective medical procedures. You can press this with both the doctor's office and the health insurer, but you might be out of luck.

Answer 6

i second the notion in fighting it, that was their in error.. You should not be held liable for their negligance.

Answer 7

fight it