Heath Insurance Billing Advice

[niccig]

I needed to see an endocrinologist late last year, so I called USC internal health and was told that they take my insurance - Healthnet PPO. Insurance rejected the billing saying the doctor was not one of their providers. DH called the USC Patient Liaison and Billing people, and was told that the Dr. was new, so the paperwork hadn't gone through with the insurance company yet, and that he was covered by our health insurance and I could keep seeing him. Fast forward 6 months and 3 appointments later, and the insurance company is still rejecting claims. I've spoken with Patient Liaison who tell me that all their providers are covered under my insurance. But Billing are now sending me bills for 100% of the appointments. I call Billing and they tell me it's not their problem as they can only do what the insurance company says is covered. Patient liaison say they can't talk to or do anything with Billing. Insurance says their computers tell them my doctor is not covered.

So, I'm getting the run around. Any advice, what the heck do I do now. I want to keep seeing this doctor, but I don't want to have to pay 100% for it.

[bluestarfish18]

I too have HealthNet and see and Endo every other month.

First, I despise HealthNet. It rated 2nd from the bottom out of 100+ insurance companies in Consumer Reports, and I compeltely believe it. Their customer service is terrible.

Second, I would try to get your Dr.'s Billing office involved. They mave have better lines of communication with HealthNet than we regular folks do.

Lastly, if that doesn't work, you may be forced to see another Endo in a different office. Since you used USC, I would triple check with HealthNet's Provider Finder on their website to have proof that a certain provider is covered. I would go as far as printing out the screen that says a certain provider is covered so you can always send a copy to HealthNet.

HHTH! Let's despise HealthNet together!

[ThreeofUs]

Document the heck out of what you just wrote (if you can - it will really help you) and send (registered mail) documentation with a cover letter requesting resolution to the head of Healthnet and Healthnet's head of CS, cc'd to your doctor, the hospital patient liaison and the billing office.

Make sure you have a follow-up conversation with every one of these people saying how much you would like to get this resolved and ask for their help and advice. Send second and third letters if you have to, noting any politicians you know who might be interested. ;)

It will take a while, but you will probably get resolution.

[spunkybaby]

I had a similar problem with my DC's pediatrician. Insurance said she wasn't on our plan, but the doctor's billing office claimed that she was. I went back and forth for a while to no avail. The only thing that helped was talking to my pediatrician--she's actually a personal friend--and telling her about all the billing problems. She talked to her billing office and emphasized her desire for them to work things out with insurance. So the billing office manager then called me and told me that I wouldn't be responsible for the unpaid charges while they worked things out with the insurance company. They eventually were able to clear up the mess by showing the insurance company evidence of the signed contract between the ped and the insurance, yada, yada, yada.

Upshot is that I recommend you talk directly with your doctor and ask him/her to intercede on your behalf. Good luck, and I'm sorry you're in this mess. It's a pain to deal with insurance.

[strollerqueen]

And these are the types of reasons why my pediatrician of 10 years will no longer take Health Net! So we either had to pay $140 per visit, or switch over to a pediatric factory that knows, or cares nothing about us. No relationship, no background, no context. But with a new baby, and two other children, what choice did I have? The whole thing is so sad.

[beansprout13]

I would try what the pp said, but if that doesn't work you can contact your state Department of Insurance and file a complaint.

[ShanaMama]

First, I despise HealthNet.

:yeahthat: I have them, too, & everything is such a hassle. I agree with the pp- document everything including names of people you've spoken with & dates. I always find it gets you further when you hang up saying 'Thank you Linda, I know you'll resolve this issue for me.' Also you can then reference the exact conversation rather than saying someone told you something & not knowing who or when.
FYI there is currently a class action lawsuit against HN for their refusal to pay out of network claims properly. I'm not sure of all the details, but I keep getting mail about it. Apparently this is a pervasive issue. When I see out of network docs (which I do regularly) I always have to pay in full & then get whatever reimbursement months later. Very annoying & not fun financially.

[niccig]

Thanks everyone for your advice.
I spoke to someone in billing who said it was a mistake and the doctor was covered, so they resubmitted the claims. They got rejected again. I'm waiting to see if billing again sends me a bill, or if someone there can work it out. The Dr. is very good, so I think if he calls the billing department, more might happen.

[Papa Joe]

I have had my share of annoyance with insurance. When we did IVF, my wife and I were told that her insurance, her specific plan wouldn't cover it even though Aetna was in network at the place... We live in NJ and had the PPO plan. What they didn't tell us when we inquired was that in NJ if you have an HMO it is covered. If that had been the case we could have switched, as we planned and saved for this a long time in advance. Since we were foolishly uninformed we opted to get my HMO plan in addition to my wife's. It covered it, but the plan in general was very lacking compared to hers. After figuring out all the costs and signing up for and paying into my insurance plan, we believed we were still going to save about $2500. So, we had both insurances going in. After getting preapprovals and everything we were off. Even though Aetna was in network, since the main procedure wasn't covered, we had to pay everything up front. Well, since my wife is the patient, her insurance was her primary. All claims were submitted to Aetna first. Her plan at the time was so good that Aetna paid for 100% of the office visits, but would not pay for the actual procedure(s), which totalled about $10,000. The total amount of office visits was about $10,000. Since Aetna was in network, Aetna had an agreement with the fertility clinic and wrote off about $4,000 of it. For example, if an ultrasound was $300, Aetna might agree to pay only $200 and wrote off the $100, and the place would consider it paid and write off the remaining amount. Well, after going through the cycle, the write-offs were $2,500. Our clinic, which again had all our money up front said that since we were not "in network" for the actual procedure, even though they accepted payment on all the regular bloodwork and office visits, we were still liable for the balance that was written off. I told them that was fine, but then they had to submit it to my insurance, my wife's secondary insurance. When we did, they said that they couldn't pay their portion of it off because it had been processed by Aetna, even though we were told we still had a balance. They instructed that it had been closed when Aetna paid at 100% and wrote off amounts. So, I went to Aetna and said, you need to reprocess all of these claims as out of network so I can submit the additional balances to my other insurance. They said no and that the claims had already been processed, and after much discussion and time agreed to place a call to their in-network clinic. The clinic would not relent. I kept persisting and went to the clinic and said that they couldn't have it both ways. They would either have to get the claims reprocessed or accept Aetna's payment in full. After months of arguing and contacting the insurance companies and the clinic, and being on hold for long periods of time, etc., I continued to follow-up on this. And persist I did. I contacted the clinic EVERY DAY and asked to speak with the supervisor. I even had others call until the supervisor, who I got to know by name, would come on and I would take the call. They weren't going to keep my money.

In my communications with the insurance companies and the clinic, I learned early on that whenever you have an issue, it is much better to ask for a supervisor up front, immediately. Well, after a long time of them holding my money, the clinic finally conceded and returned my money, although it was 7 months after the procedure.

There were other things that happened in my quest as well. After first signing up for Aetna and my insurance we were initially told that fertility was covered and then told again when we went to get approval that it would not be covered. Checking to see if NJ had a policy that allowed for fertility seemed to be beyond them on different days and occasions.

So, I feel for anyone with insurance/medical difficulties. I believe that they simply deny every other claim just to get you to back off. If 1 out of 5 people thought that it was just not worth the trouble, look what they would save. As for that clinic, they rake in money hand over fist, and they had to fight me for my $2,500 when they got over $15,000 for their services.

I was much more prepared going in for the second and third IVF cycles.

Lessons learned. Have a copy of your policy. Know your state's rules. If you have more than one insurance know how they work together. Document and save everything. Except for minor things, ALWAYS talk to a supervisor or a supervisor's supervisor. Get the person you are talking with's name/Email/contact info, etc.. Don't take no for an answer. Talk with the medical approval department and not the reps that are trained to be vague and say NO. Get clarification and get it again. And never give up!

I still call the clinic and ask for the supervisor and ask for my money, even though it has been three years and I have received it. I was that annoyed and it is fun every once in a while when I am bored.

[amandabea]

ugh, this post brought up bad memories for me! so with no intentions of hijacking let me relate my insurance nightmare...in this saga the provider is PacifiCare...

Got pregnant in May during employer's open enrollment period. Called Pacificare to see if they cover my current OB and call doctor's office to confirm. Was told 'yes' by both parties so I switched ins effective July. Continue to see OB throughout pregnancy. Get pre-authorization from Pacificare to have baby at local hospital. Have baby in January. Receive "explanation of benefits" from ins stating they will not pay for doctor's delivery fees (hospital charges are covered) or for any of my postpartum oB treatments/visits. Contact ins every day for over 6 weeks to resolve issue, get disconnected at least 2 out of every 5 calls. CS rep says my OB was never covered and states that all claims throughout the past 9 mos never should have been paid! Call daily. Am finally told that for my employer the only employee's who can see my OB must be part of the No California plan...I'm part of the So California plan...never mind the fact that my OB's office is in So California! Call employer's outsourced benefit center daily to no avail, get disconnected several times, never receive return calls. Almost lose my mind completely when crying/nursing baby makes it impossible to use the f@#$&^) automated voice response system. In the meantime, I add my newborn to my ins and when we go to the pharmacy to fill a prescription am told that we have been dropped from our ins. So I pay full price for the meds and have to open new "issues" with ins provider and benefit center. I ended up calling colleagues in the benefits department at work and after 2.5 months everything was resolved, but for 6 of my 8 weeks of leave I called both the insurance and my own benefit center EVERY day.

The morale of the story is document everything, request the ins CS rep document what they tell you in your file, and call to follow up on everything...oh and get to know someone in your company's benefits department.

[spunkybaby]

After reading the PP's stories, I just wanted to encourage you to talk to your HR benefits rep (perhaps at your DH's company?) if you have group coverage. The HR benefits rep has more "pull" with the insurance company than you do and can fight on your behalf. If you are able to get the doctor's office to fax your benefits rep the paperwork showing that the doctor is contracted with HealthNet, the benefits rep may be able to persuade HealthNet to change its tune.

Good luck, and again, I'm sorry you have to deal with this. Lots of hugs!