Insurance company is supposed to pay 80%, but they won't pay anything?

Question

If your insurance company is supposed to pay 80% of a procedure, but then refuses...is there any recourse in a matter like this?

It really isn't for me. I know someone I want to make a deal with, and know that he had double knee replacement and this happened to him. I thought that maybe if I helped him out with his problem, it would increase the chance of me securing the deal.

Answer 1

You need to be more specific as to the reason for the denial.

When you have a plan that is supposed to pay 80%, it doesn't mean "80% of whatever gets billed." It means 80% of the allowed amount for approved procedures done by network providers.

If you post more specific information, it might help. Why was the claim denied?

For example, if the surgery needed pre-approval and he didn't get that pre-approval, then there would need to be medical records sent to the insurer showing why the surgeries were necessary.

Also, any appeals would need to be done within the appropriate appeal time frame. If too much time has passed since his denial, there won't be anything he can do about it. (Normally an appeal time frame for a claim would be something like 180 days after the denial, but it can vary from policy to policy.)

Answer 2

Every insurance company has this disclaimer: "Quote of benefits is not a guarantee of payment. Actual benefits are determined when a claim is received." Or some variation on those exact words. It pretty much means that they can tell you whatever you want to hear, but DO whatever THEY want.

The first recourse a patient has in a case like this is to appeal. Provided that the procedure is covered in the contract (you can not force an insurance company to pay for an uncovered procedure.) and medical prudence or medical necessity can be documented and proven. Enlist the help of the doctors treating this person. Start with calling member services for the plan (if you're not the patient, you can not do this due to privacy laws) and ask for the appeals process - including contact name address and phone number. Follow those instructions to the letter. Keep copies of EVERYTHING sent. Send any documents certified. Start following up in two weeks after the date the paperwork is signed for. (Squeaky wheel....)

Answer 3

Working from the carrier side myself I can promise you that there is some position the carrier took with regards to the procedure. In the highly regulated insurance industry you cannot deny a claim without cause.

The first step will be to call the member services with an explaination of the denial. There are four cookie cutter answers:

1. The procedure was not pre-authorized.

Corrective Action: Call doctor whom recomended the procedure to do a retro-authorization. This should fix the interuption.

2. Lack of information supplied.

Corrective Action: Document the request information and produce the same to the carrier.

3. Not medically necessary.

Corrective Action: Have the insurance provide you a document with their medically necessary criteria for the procedure. Then take the document to the doctor to address the same. If that doesn't work, file an appeal with the carrier.

4. Contract excluded care

Corrective Action: Nothing... you only get what you pay for... Ask for a copy.

Things not to do... Refer to Michael Moore as he is under the impression that the communist republic of Cuba has better healthcare.

Answer 4

There must be reason why they won't pay. They must share that information with the patient. Did they say it was for a preexisting condition?

Insurance companys suck. I suggest you and double knees see the movie "Sicko" it will give you some insight into the health insurance industry and how you might be able to fight back.

Good luck!

Answer 5

properly, in the experience that your brother's coverage has a deductible or coinsurance, he's answerable for those quantities. (Coinsurance = the share which you're answerable for. ex. eighty-20 insurance, the insurer pays eighty% of allowed quantities, you pay 20%.) i'm no longer shocked that he won costs - its uncommon for a individual to have a coverage at present that covers at one hundred% without deductible or out of pocket cost. right here is what your mom is thinking of: in the experience that your brother had centers completed at a community scientific institution, the scientific institution is had to settle for the insurer's decrease fee. yet your brother continues to be answerable for his deductibles/coinsurance/non-lined expenditures. Ex - (For sake of clarification, enable's anticipate eighty-20 insurance, no deductible or out of pocket max.) The scientific institution costs $15K. The insurance corporation says that the standard fee for the centers is $10K. With the eighty-20 occasion, the insurer might pay $8K, your brother might pay $2K, and the scientific institution might write off the $5K. The scientific institution might ought to settle for the $5K decrease fee from their invoice, yet your brother might nonetheless be answerable for his 20% (the $2K = 20% of $10K).

Answer 6

80% of covered procedures with covered facilities and it has to be within the scope of the policy limits and coverages. So no it is not guaranteed