INSURANCE AND DOCTOR

I have a strange problem!  My Insurance has told me that my Doctor is "in-network" and DS is covered and the hospital is "in-network".  They have checked the procedure codes and all is good.  My BMI is right on for their approval......I have met the 6 month meetings with the doctor requirement.  You would think that I would be all set.  BUT:

My Doctor's  insurance people say that he is "out of network" for this procedure and that my BMI is not high enough for my insurance to cover it.  They want money up front  (ALOT), because THEY say my insurance won't cover! 

Any suggestions would be GREAT!


I really DON'T want to accuse them or consider the possibility of fraud, but that is what it is looking like
To top it off, he is the ONLY one in my area that does this procedure.........HELP!!

                            Thx, Diana

First, call your insurance company yourself and give them the doctor's tax ID# and NPI #  (if you need help getting those, let me know...I know where to look them up) 

Also give them the diagnosis codes and procedure codes  (if they haven't already given them to you from the office...you can call them and ask for them.

Ask the person you speak to at the insurance company for a reference number for the call.  If they cannot give you one, ask if your doctor's office can call that person back directly and get the number and extension.

Once you've called them and confirmed that the doctor is, in fact, in-network and those procedure codes are covered if performed by him.  Call the office back and ask to speak to the billing manager.  Tell him/her who you spoke to at the insurance company, what time of day it was and the date and let him/her know the information they gave you. 

If the billing manager is not willing to do this, then it's time to talk to the doctor directly and bring all your information with you.  Most doctors hate it when a patient has to come to them with issues like this and they will make sure it is handled correctly.

I'm sure you've done at least one appointment with this doctor during your process, how were the claims processed?  In-network or out-of-network?  If they were processed in-network then I don't understand their problem.  Point out that to them as well.

Stick to your guns and keep pushing.  You are your own best advocate.  Let me know if you need help looking up those ID#'s.

Thank you so much for your help!!!!!!!   I now know what I need to bee asking and looking for as far as IDs and codes go! 
I have been to a seminar with the doctor.  My appointment is next week.  I was originally going with another procedure and another doctor.  This  appointment is with the doctor that my original doctor recommends.
At the seminar (which was the doctor, myself and 1 other person), the doctor even said that some procedures were covered and some were out of network for him.  I am concerned that money is HIS deciding factor.
I will start asking for his ID and codes 1st thing at the appointment, as I know the insurance people from his office will be part of the consult,
Once again, Thank-you for your help and I will get back with you, I am sure.

PS   The appointment IS covered by my insurance

                                                                                                    Diana

Diana,

Check to see if the insurance company is confusing you with another person.  As stupid as that sounds I got a call from my insurance company the other day and they told me "UHC said your BMI isn't high enough (I wish) and they won't cover your surgery."  I of course replied "I have BC/BS, I had my surgery on 3/29 and hell yeah my BMI was high enough for two surgeries". LOL  She then told me, Oh I have the wrong person.  Great job babe, I'm happy I'm with you guys.

Incidentally my insurance company has yet to pay for the doc, they paid for the hospital part of it but not the doc.  So when I got the first claim denied by the insurance company because they needed more information from my surgeon, I called the surgeons office and was told "don't worry, I work with your insurance company every day, they pay xxx dollars and you WILL NOT GET A BILL."  Yesterday my surgeons office sent me a bill for $36,000.  Yeah, I hope he's not banking on that money from ME! 

Please make sure your surgeon's office is totally on board with all approvals.  If they aren't going to work with your insurance company then its going to fall on you to make sure all claims are paid.  It's difficult at best working through all this stuff, that is why our surgeons supposedly get the approval before the surgery takes place and work through insurance.  Clearly not a flawless process!!

Good luck!!

Donna

The doctor is either in-network or out of network.  It doesn't go by the procedure...they don't know what they're talking about.  However, different procedure codes may be covered differently.  Some may have a higher out of pocket depending on your employer's contract with the insurance company. 

It would be best to get your hands on ALL the cpt (procedure) codes and then call your insurance to find out the exact coverage.

 Thank you!  Would the doctor be willing to give the procedure codes or is there another way to find them?

I SURE DO APPRECIATE YOUR HELP ON THIS!
                                                              Diana

I would ask the billing manager for the codes.  They really have no reason to deny giving them to you.  Just explain to them that you want to do some verifying with your insurance and your employer so you can plan accordingly for your share of the financial responsibility.   He/she may say they have already done that, where you can say how much you appreciate their hard work but you want to speak to your insurance yourself as well in order to be 100% prepared.  If he/she refuses, then I would go directly to the doctor and ask for them.  If the billing manager knows you are going to the doctor (if she refuses), she may become more cooperative.  Worse comes to worse, you may have to find a different surgeon.