Insurance issues post op

 Thanks Tali!! 

I will start by saying I am NOT an insurance expert. However, just from reading the situation, it looks like some dolt at the insurance company is denying your claims based on the CURRENT policy (WLS exemption) as opposed to look back to the 2008 policy. It really does sound like a big, stupid, stressful clerical error - I'm confident it will get sorted out!

Take a deep breath. I have received insurance EOBs stating claims were demied or even paid and then turned around - my doc's office has always straightened it out without even contacting me, so I have never been billed for anything. Hopefully, your surgeon's office and/or hospital will help you through this.

Melissa -

I'm a little nervous about something you said in your post...  You say that any WLS requires preauthorization -- my surgeon's office told me that as long as I have met the criteria (which I have) and as long as my insurance is in effect (which they verified) then my surgery will be covered, as it is a covered benefit.  However, there is no real preauthorization that has been done, to my knowledge.  Am I reading too much into this?  I'm sure they know what they're doing, as they do it all the time; but, geez I'd hate to end up with a big honkin bill after all is said and done!

Any insight or suggestions - my surgery is June 3rd.

Thanks,
Stephanie

Stephanie,

Remember that a pre-authorization is your physician tells the medical team at your insurance company your medical information and if your meet the criteria you are approved --- the reason the letters state this is not a guarantee is because some policys exclude WLS.... Although not fair you can have pre-auth but if you do not have the benefit you will be denied..... If I would you I would call and make sure WLS is not excluded....

Good luck and congrats on your date....

Chrisi

Stephanie,

There is no guarantee, however, you can be assured that GHP feels pretty damn confident that THEY are going to be paid by your insurance company (because they have likely worked with them over & over again), or YOU would be asked to fork over some amount of money UPFRONT.

Very few insurances guarantee payment up front.  Some don't even pre-auth (like BCBS-MI), but the insurance experts in the surgeons office know what to expect based upon their experience with your insurance.

Also, when you get the pre-admit call from Blodgett, they are also looking at YOUR responsibility for THEIR bill.  Some have been surprised that they need to come up with $$ for the hospital, that the bariatric practice didn't tell them about (they wouldn't have known to tell you, as it usually has to do with deductibles / in -or- out of network, etc...).

Personally, I paid the program fee (at MMPC at the time), and that was all I had to come up with.  It was not part of my yearly deductible, but I had already met that for the year.  Others had part / all of that covered by their insurance, so the fee amount can be different.

Go with what GHP has told you, and don't worry about it.

Just to be sure, call your insurance company yourself.  Most insurors require certain criteria or tasks be met before they authorize the surgery.  Better to be safe than sorry.  The surgeon's staff do NOT know everything.

Do you have copies of your EOB's from 2008 that says they were originally covered, except the one charge?

 I am not sure about that I know i have the one, where the charge was denied, but it did show the other two charges as paid.  I will have to check at home...good idea, thanks!

Kat,

Remember that a pre-authorization is your physician tells the medical team at your insurance company your medical information and if your meet the criteria you are given pre-certification--- the reason the letters state this is not a guarantee is because some policys exclude WLS.... Although not fair you can have pre-auth but if you do not have the benefit you will be denied.....

I hope this is all a big mistake and can not imagine what you are going through...

(((((BIG HUG)))))

Chrisi

Okay, relax.  You've got a couple of options here.  First of all, I'm with the others about investigating the clerical error.  I'll bet your HR dept can get you a copy of the 2008 benefits summary, so you can see and share that there was no exclusion in 2008.  I'm praying that this error is cleared up, but if you've extinguished the insurance route to no avail, here's my plan B.

There is a grant fund that helps pay for hospital bills for the uninsured that can't afford to pay.  I had a friend tell me about this because her son was a severe diabetic and unemployed to boot.  He'd had a couple of expensive hospitalizations and wound up only oweing a couple of thousand dollars.  I gave this same information to a family friend who was in a car accident with her spouse, and for whatever reason their auto insurance gave them the runaraound.  Their bill (after brain surgery, traction for a couple weeks...the works) was only a couple of thousand dollars.  The hospital has the paperwork and will even help you fill it out if you need it (because they want to get paid).  It's not advertised, but it's there for those who ask for it.