Insurance issues post op

As I have posted before, one of my claims was being denied after surgery, it was just the one for the surgeons fee of 5000$.  We I filed a complaint with the PA insurance review, and they stated they could not help me.  Suggest I file an appeal with the insurance company.  Well the reason I didn't do that in the first place was because the insurance idiot on the phone told me I could not because it was an exclusion on my policy and I could not appeal.  Well I still had time to appeal so I did anyway.  I got a letter stating they were reviewing it, thats it so far.  We today I log on to my insurance website and look back over all the claims and now they are all marked as DENIED!!  Well over 200,000.00 dollars worth of claims....I am shaking as I write this and am having a meltdown, quietly here in work.  So far I have not heard anything, but I need to check my mail when I go home to make sure.  Here is what the codes say...

Reason Code	Reason Description
BA4	ADJUSTMENT: ORIGINAL CLAIM WAS OVERPAID.
P13	CHARGES INCLUDED IN CONTRACTUAL ALLOWANCE. PROVIDER LIABILITY.

 This one was for the hospital, this next one for the doctors office,  and the anesthesiologist one said this also.

B87	THIS CLAIM/SERVICE IS DENIED AS THE PROCEDURE OR DIAGNOSIS BILLED IS NOT COVERED UNDER THE BENEFITS OF THE MEMBER'S CONTRACT. MEMBER MAY BE BILLED FOR THE CHARGES.

Previously these were all marked paid.....what they hell is going on here??? Any advice would be appreciated.  Did I cause this by filing an appeal for the one thing they were trying not to pay?  Do I need a lawyer?  OMG....

1) Did you have a pre-op preauthorization?
2) If so, submit a copy with an appeal to your insurance company
3) This is a game that insurance companies sometimes pull -- they give you an unreasonable denial post-op, and because you are scared of ruining your credit, and afraid there is nothing you can do, you pay and they win.  Don't let them get away with this.
4) Go to your HR department and see if they can give you some help
5) Don't miss any deadlines on your internal appeals or you waive your rights!!
6) Yes, I would contact a lawyer if this isn't resolved in the first appeal to the insurance company -- you could lose your house and your credit!

Insurance companies are preditors.

 Yes I did have pre-op pre-auth, but they keep stating that is not a garuntee of payment, I did not include that with the appeal I sent.  But I can get a copy and include with the next go round if needed.  Fortunately or unfortunately, I already lost my home last year and my credit is already shot, so the can go scratch, I ain't afraid of ruining that.  I did try to contact my HR department before and they were no help whatsoever.  I guess I will see what happens with this first appeal and go from there, thanks Diana for your advice.  I just can't believe they can do this.  

Here are a couple of further things to remember:

1) If you were preauthorized, you should be OK for at least some of the payment
2) If your providers (separately, the surgeon and the hospital) were in-network, they are required to accept as payment in full from the insurance company the amount of money that the insurance company says is UCR, including the amount/percent of that number that is the insurance company's responsibility (e.g., 80%), plus the amount of that UCR that is your copayment (a fixed number like $100 or a percent like 20%).  The providers cannot ask for any more than that.
3)  If either or both of your providers are out-of-network, you will be responsible for the ENTIRE charge that is greater than the percentage of UCR that the insurance company is liable for.  Could be a BIG number.  The insurance company has to pay something, but not that much, and the provider can look to you for the full difference between that amount and their full fee.

Take a deep breath :)

Did they precertify or preauthorize the surgery ahead of time??  I work for an insurance company and it requires precert any time a weight loss surgery is performed. 

More than likely, it's just some sort of clerical issue...so don't freak out yet.  The first denial sounds like it was an overpayment that was retracted and it doesn't sound like liability is being placed in your lap. 

Double check what procedure codes and diagnosis codes were billed under your contract.  Did you verify your benefits?  I am seeing a lot of policies that either completely exclude morbid obesity as a diagnosis OR they exclude it in any case except for WLS.  If you want to PM me any additional information, I can tell you how I see it from the customer service viewpoint.  

Don't get freaked out yet though...you don't need additional stress :)

 Melissa, now as of 2009 I do see any kind of WLS listed as an exclusion on my member benefits.  But this was not the case when I started this journey in 2008.  I read everything I could, and could not find any exclusions.  I did not call them, I assume that all the hoops I jumped through pre-op and my submission for pre-approval was enough, and I was good to go.  I agree with on the one about the liability, it does sound like they are taking liability for that but the other ones they are denying are the anetesiologist, the surgeons which is well over 10,000$.   I will wait to see what happens, I haven't been officially notified yet, I just stumbled over this on the website.  So well see.  Thanks for your help.

Your surgery was in 2008 though, right?  When did you get the denial?

I would call customer service first.  Tell them that you are verifying benefits from 2008 and ask them to give you the benefits for the surgery.  If they tell you that you have the benefits, have them look at the claims and tell you exactly what is going on with them.  IF YOU FEEL THAT THE PERSON ISN'T INVESTED IN HELPING YOU AND SOUNDS LIKE THEY DON'T CARE, ASK FOR A SUPERVISOR.  You need to have someone who is advocating for you :)  

If you get further information from them, let me know and I can tell you where to go from this point.  I do pretty damned well getting things overturned for members that I assist.

 Yes, my surgery was in 2008.  The first denial I received was in 11/2008 for the surgeons fee..  That was the only denial, everything else was listed as paid.  The hospital and the anesthesiologist.  Everything was in network to answer Diana question.  Even when I reviewed everything a little while back everything was fine, only that one charge was the one they disputed.  Now suddenly I look and see this.  As I said, I haven't gotten anything from them yet so I will let you know, I don't want to call until they officially notify me of this.  I am afraid to call at this point.  But I will take your advice and call when/if they send me something, and I will ask to speak to a sup.   The guy last time just kept repeating that a preapproval is not a guarantee of payment....UGH!

Kat - it sounds to me like you had a crappy rep assisting you.  While preauth is never a guarantee of payment, he should be able to tell you exactly what is causing the claim to deny!  That sucks!!!

Kat, just wanted to send along a big hug! *hug* This is not a fun thing to go through but I have faith that it'll work out. Just take a deep breath and start gathering the papers necessary.