Question:
How can my surgery be approved when the consultation was not?
I recently found out I am approved for my surgery. YAHOOO! But then I just got the bill from my first consultation with the surgeon, $348 with a note on the bill saying in fine print "not covered by plan" . I called the insurance company and sure enough, it's not covered. I don't understand how they can approve the surgery without also approving the consultation? It's not like I could have the surgery without meeting with the surgeon first! Can I appeal this? — Laurel C. (posted on July 16, 2002)
July 15, 2002
My only question is - Did your PCP refer you? If not, I know my insurnace
wouldn't cover the appointment either. You might want to check on that.
Good luck and congrats on the date!
— AphY Girl
July 15, 2002
I'm not sure it's worth appealing, Laurel. The same thing happened in my
case, but don't panic or let that alarm you. I'm so excited about just
HAVING the surgery and QUALIFYING, right now, I'm not too much concerned
about anything else!! The mere fact that I am afforded the opportunity for
a quality of life I've not had in a VERY long time. I've now gone into some
*serious debt* to have this surgery, but it's because I'm on a mission and
I'm not letting ANYTHING STOP ME! You have to assume an *attitude*,
so-to-speak, and have the DETERMINATION to press on through this seemingly
minor obstacle. You can't fault the surgeon, he has the insurance/billing
staff that probably checks out your coverage BEFORE you are even scheduled
for the initial consult. This may happen IF your PCP didn't refer you or
the surgeon you selected was not in your *network* for your insurance. $348
is a drop in the bucket compared to being a *complete self pay* and having
to foot the entire bill (total cost of the surgery). You didn't mention the
type insurance you have. As the previous poster asked, "Did your PCP
refer you?" I realize the insurance company not paying this amount has
upset or discouraged you, but look at the MOST IMPORTANT THING, your
SURGERY IS APPROVED~~which means, more than likely, it's covered!!Look on
the BRIGHT side, and don't sweat the small stuff. Hope this helps.
— yourdivaness
July 17, 2002
Laurel, I would let it go for now. I was approved for surgery, then 12
days before my date they sent me a letter of denial. Emotionally I am
ready to go off the deep end. In the meantime I am getting bills for all
of my pre-op testing. They do not want to cover that either. I am not
going to pay for anything until I hear about my appeal. I just wish I
would have gotten the denial after the surgery was already over. Then I
would worry about paying for it. I just wouldn't risk talking to the
insurance company for 300 or 400 dollars in case they would deny your
surgery.
Susan Wagner
— Susan W.
July 17, 2002
Hi Laurel,
The same thing happened to me and it was a coding error; they coded it
obesity and left off the other comorbids. Maybe your surgeon's office
should resubmit with the other diagnoses first, particularly if you have
gallstones...that was the clincher for me.
Take care and best wishes...
— Ann B.
July 18, 2002
Have your doc submit the claim again. Alot of the times the insurance will
pay if they are notified that the surgery was approved. You could try
calling your insurance and ask them since the surgery will be paid for why
not the visit. It's worth a shot.
— Kevin D.
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