Insurance SNAFU

So, I thought I was only a few days from full approval when I get a note on Friday saying my insurance has denied the surgery because it isn't a covered benefit. WTF??? It was covered when I looked at at my coverage online, and was covered when I call to confirm coverage. I spent 40+ minutes on the phone with the insurance people on Friday trying to figure everything out. Once we got talking, they said that NONE of the pre-surgery appointments would be covered (!!!), even if the surgery is covered, and whoever told me they were covered was "wrong". Finally I got a supervisor who seemed interested in helping me and she is still working on it. Apparently, their pre-cert dept doesn't have the right info, so they have to call my employer to make sure it is covered. I am so upset and depressed -- I thought I would have my surgery date by now, and I'm back arguing with the insurance company. And if it's true that the pre-surgical appts aren't covered, I'll be on the hook for over $1100. Keeping my fingers crossed that everything works out -- quickly.

If they have to call your employer to find out if the pre-op work is covered, I suspect that you are on a self-insured plan.  That means that the insurance company only administers the benefits, and that the employer group is the entity that is at risk for the cost of care.  This is important to know because it means that state insurance laws and protections do not apply (they only apply to insurance companies that are taking the risk for the cost of your care.  They do not apply to employer groups), but luckily federal laws do.  The employer group determine what is covered and not covered under a self-insured plan.  Generally, for a fully insured plan (insurance company takes risk), if they pay for the surgery they would pay for the pre-op.  All rules are off for a self-insured plan.  Do you have a summary plan description from your employer?  That should lay out your covered benefits in detail.  Good luck!

Maryann

I don't think we're self-insured, but I will check with my HR dept and see. Thanks for the info...