So stressed and frustrated with medical insurance

[SpaceGal]

UGH I know I should rant this in the Bitching section but I also need advice and any BTDT situations.

DD was born in Feb this year...a very happy time of course...three weeks later her brothers get sick and I wait and wait for her to get whatever they got....then it happens. Her temp drops to 93 degrees and we rush her to the ER on a Friday night. All that time I waited for a fever not expecting hypothermia. Anyways, admist all that it turns out she had pneumonia and had to be admitted to the hospital. Well between running back and forth to the hospital and taking care of my two boys and trying to keep their lives sane and normal I was just trying to be calm.

Anyways, a month later we get a bill...$13,000!!! I freak out. I called the hospital and the inusrance. I guess the first time the insurance tells me that well we have to verify that you don't have other insurance...no we don't I can't imagine who can afford to have double health care these days. Anyways, I call every week to check...and then they say they have to reprocess and what not. Now fast forward to last week, they tell me I never called for pre-authorization for my DD to be in the hospital. I told them she went to the ER I don't know what happens beyond that I never knew I had to call them. Mind you it was a Friday night and they didn't admit her into the step-down unit (not ICU but not regular unit) until 2AM. UGH...the rep admits she knows that's the last thing on my mind when I have a baby in the hospital. They tell me they need medical records to prove that she needed to be there and what not. Here I am fuming and upset as hell. I mean I been calling at least once a week for the past 6 weeks to follow up and check on this situation and all they been telling me is that it's in process process. Finally, they say they are drafting a letter to the hospital to ask for records and whatnot. The rep could even see that the baby was in the hospital for pneumonia...I mean a 3 week old baby isn't going to go home you know they are going to keep her...and no SANE parent wants their child in the hospital!!

Then yesterday I get a letter saying that 45 days has passed and so the claim is being rejected. UGH after all that crap they did to me...now I have to file an appeal!!! I know that's not going to be pretty!

I just hate it all seriously. I mean goodness what is a normal person to do. My DH is all mad and tells me he refuses to pay that bill but ultimately the insurance is screw both us and the hospital. I mean fine I forgot to call for pre-authorization and if they needed paperwork after the fact they could have just said so and what not and then it could have been done...but no. I'm just so angry like I can't even think about other things but that. All I think about is that crazy night as I drove her to the ER thinking I was going to lose my baby to some crazy illness...standing there as they did the chest xrays and spinal tap and all other lab tests...and among all that I was "supposed" to call to tell them all that, while I try to keep myself together.

Tell me the appeals process isn't going to kill me and send us to collections. I'm so worried and mad of course. Ugh...thank you for listening...I just need to get this done and over with but I know it won't happen so quickly.

[s7714]

:grouphug: Sorry you are going through this.

Have you tried asking the hospital billing department for assistance in getting the matter cleared up? IME hospitals are sometimes willing to help because they want to be paid! We went through a similar (although relatively minor compared to yours) situation a couple years ago when my older DD had a round of routine x-rays. Our insurance didn't want to pay because they didn't think it had been pre-approved. Turned out the hospital was supposed to bill the medical group first who would in turn bill insurance. As soon as I talked to someone in person at the hospital billing dept. the matter got cleared up in about a week. I'm sure YMMV depending on the hospital though.

Hope yours gets straightened out soon!

[ha98ed14]

Wow. I can't even imagine. I'm so sorry. Personally, after watching that movie by Michawel Moore, I think it is SOP for them to deny everything and see how much of a fight you will put up. For the future, would you consider switching to an HMO? A lot of people think they are evil, but for relatively heathy people who just need routine care, they are a lot less expensive and since everything is done by referral, there is no pre-authorization. Our DD had surgery at 9 mos old to correct a birth defect. She was in ICU for 3 days and the regular ward for 2. We didn't pay a dime except our normal primium. It was a gift from Heaven.

[happymomma]

I am so sorry that you are going through this. I hate insurance companies. I think they try every possible method to get you to give up and end up paying for it yourself. I would just fight them as much as possible. We had this when we were going through Occupational therapy for my son. Even though we were approved for his OT, I had to fight them every time I submitted a claim (which was once a week). It was awful. I started having anxiety attacks when I knew I had to call the insurance company. I was just so glad when he didn't need OT anymore.

[cuca_]

As someone else said, I would contact the hospital and explain the situation. Let them know that you are working with the insurance and trying to solve this and see if they can help you in any way. Next, check the terms of your insurance. I think for a lot of insurances the pre-certification req. is waived when you are admitted through ER. I know that my DS was admitted through the ER a year ago and ended up having surgery, and I certainly did not call the insurance while we were dealing with it. If your insurance is through your work or your DHs work, they might be able to help you in sorting out the terms.

As to the closing of your claim, I would call them before filing an appeal. You were working with them at the time and in contact with them, I can't imagine that they can rightfully close the claim at this point relying on the expiration of the 45 days. They might be able to do this, but I would fight it. Also, I would tell them that you are writing a letter to the Department of Insurance, because you feel that you are being treated unfairly. Insurance companies often respond to that. And if you can I would confirm my conversations with them in writing and copy the Department of Insurance in every letter/communication you have.

Good luck and hugs to you. This must be incredibly stressful.

HTH

[kijip]

What total cr#p! Seriously, my first call Monday morning would be to the state Insurance Commissioner's office to see how to file a complaint. Then I would call the insurance company and explain that you have made/are making a formal complaint. Then I would call the hospital and ask them to flag your account so it does not go to collections while the dust settles. They can't let the clock run out on the claim by telling you it is in process for their entire billing period.

In some states the law requires them to waive pre-authorization for ER admits or anything where it would be impossible to reach them for pre-authorization when the care is needed immediately. Our insurance has no pre-authorization required for pretty much anything. I count myself lucky for that.

[LBW]

If you haven't done so already, sit down and make a timeline that shows all the events related to your daughter's hospitalization and your contacts with the insurance company.

Then do what Katie said!

It's amazing how quickly someone from the insurance co will contact you when you file a complaint with the state!

[KrisM]

If it's something that should be paid for by your insurance then DO NOT PAY IT! Getting reimbursed by the insurance co will be much harder.

Call the hospital and let them know what's going on and that you're working on getting insurance to pay it. They should be able to mark your account so that it shows that and they won't send you to collections. Ask if they can call the insurance co. for you.

Good luck.

[Momof3Labs]

I wouldn't go to the department of insurance yet, and don't waste one of your appeals at this point either. I'd first exhaust other options. Call the hospital and have them resubmit the claim, plus find out when they plan to respond to the request for the medical records. Call the insurance company and question why it was closed when they were still waiting for records (was the 45 day time limit on the records?).

I've dealt with plenty of medical insurance headaches and find that a phone call to the insurance company (and sometimes to the provider) usually gets things back on track. I've never had to resort to an appeal, but one time recently I had to turn to my employer to get things paid correctly (I hate Medco even more than I hate medical insurers).

Just out of curiosity, have you checked your policy or summary of benefits to see what the pre-authorization requirements are? They shouldn't have required you to call on the way to the ER, but sometimes do require a phone call within, say, 48 or 72 hours of hospital admittance. Once you know exactly what those requirements are and whether or not you complied with them, you know whether you have grounds for a complaint with the department of insurance should all else fall through. But IME, the fact that they are requesting her medical records means that they do plan to pay their share, albeit slowly.

[Beckylove]

I understand your pain. I had DS in July and the insurance company finally paid out last week after denying the claim 4 different times. First for double insurance, then for double insurance again, then for not eligible at time of service, then double insurance again. It was a mess.

My advice:
1. Keep all documentation and notes about who you talked to at the company, what was said and when the conversation took place.
2. Keep calm on the phone. The front line paper pushers that you will be talking to aren't out to get you. They are people and being civil is a better way to get them to help you "sort out the mess."
3. I just kept calling, asking what addition info they needed, and sending it in. When they wrongly denyed the claim again, I called them, explained what was wrong, asked them to reprocess the claim, again. Be persistent.
4. Call the hospital and tell them what is going on. They might put your account on hold until they receive a status update from the insurance company.
5. If your plan is supposed to pay 80% of hospital bill and you know that there will be a balance left, you might set up a payment plan with the hospital for the amount that you will have to pay sooner or later anyway. That will appease them while you sort out the insurance.

I am so sorry you are going through this. I know how bad it sucks. It is a horrifying feeling to open the mail and get a bill for thousands of dollars. Just keep after them.

[lorinick]

Wow so sorry. I think before you go to the hospital your suppose to call your peds office even after hours. They have to say for you to go. That is what I've been told. I would say that you spoke with someone after hours and you were told to bring her in. insurance does anything it can to not pay out a claim. Dealing with insurance is such a headache. I had problems with my insurance claim I had a lapse in a ref. and they weren't going to pay for my fert. treatment of 10,000.00 I too was dying and lossing sleep over it. The doctors office told me not to worry about it they would deal with it and that this happens so ofen. I'm sure it will work out and they will pay. There trying to make up a reason to not pay. Your little one had a true medical emer. and that should be it no pre cert. needed. Also agree with other poster and also what I did have the hosp. resubmit the bill again.

[VClute]

Years ago, before becoming a nurse, I worked for a couple of major insurance companies. I can tell you that insurance companies are NOT scheming to avoid paying your claim. Everything is automated to a point that COMPUTERS are denying claims, not people. The people in the customer service department are there to help you interrupt the computers' machinations. When they told you the claim was "in process," they were just reading what was on the computer screen. No one there is in business to rip you off.

I would first calm down and understand that the hospital is not going to send this to a collection agency unless the insurance company tells them they don't insure your family. I would call the hospital to a) let them know you're working on getting the claim paid and b) encourage them to send/do everything they need to do/send to get the claim paid.

I would not have them resubmit a claim (It will be denied as a duplicate to the first claim.) I would have them send the documentation that was requested and have the denied claim reprocessed.

Then I would call the insurance company and let them know you've talked with the hospital. Be as kind to the customer service rep as possible. (I would go out of my way to hand walk claims for people who were really kind to me.) Ask for a fax number that the necessary records can be sent to. Or an email address.

I'm so glad that your baby is ok now. What a blessing!

[strollerqueen]

Ugh, so sorry you have to go through all this. My middle son had a very expensive ear surgery a couple of years ago. It wasn't optional-he had to have a tumor removed that eventually would have killed him. I did everything I was supposed to do, sat down with the hospital's finance dept., paid them a $1,000 deposit, got it all approved through my insurance. Everything was paid, and everything was fine. Or so I thought. A year later, after I had just had a baby and was in the middle of moving, I got a bill from the hospital for 3-grand from the surgery. Nothing was explained. Since I knew everything had been paid, I figured it was an error. The next thing I know, I am getting phone calls and letters from a collection agency for the amount. It took me numerous phone calls to figure out why I was getting the bill, (and when you are moving into a new house and have a new baby you have so much extra free time to sit on hold and get passed around from dept. to dept and place to place) since no one would come out and say it. Apparently the insurance company decided they had overpaid, and made the hospital pay them back. So the hospital then came after me. To add insult to injury, the collection agency has added a huge amount of interest to the debt, starting from the date of the surgery. This, despite the fact that they HAD the money from the insurance company! Now the hospital says it's out of their hands and the collection agency can do whatever they want. The collection agency says they can do whatever they want. The insurance company says the same thing, but also that I should hire a lawyer. Hire a lawyer for their error! WHat the..so I respectfully disagree with the previous poster. I have been nothing but nice and polite to everyone I have spoken to. It got me nowhere. And insurance companies have paid huge fines to the state from pulling these type of scams. I do wish you have better luck.

[kijip]

Ugh, so sorry you have to go through all this. My middle son had a very expensive ear surgery a couple of years ago. It wasn't optional-he had to have a tumor removed that eventually would have killed him. I did everything I was supposed to do, sat down with the hospital's finance dept., paid them a $1,000 deposit, got it all approved through my insurance. Everything was paid, and everything was fine. Or so I thought. A year later, after I had just had a baby and was in the middle of moving, I got a bill from the hospital for 3-grand from the surgery. Nothing was explained. Since I knew everything had been paid, I figured it was an error. The next thing I know, I am getting phone calls and letters from a collection agency for the amount. It took me numerous phone calls to figure out why I was getting the bill, (and when you are moving into a new house and have a new baby you have so much extra free time to sit on hold and get passed around from dept. to dept and place to place) since no one would come out and say it. Apparently the insurance company decided they had overpaid, and made the hospital pay them back. So the hospital then came after me. To add insult to injury, the collection agency has added a huge amount of interest to the debt, starting from the date of the surgery. This, despite the fact that they HAD the money from the insurance company! Now the hospital says it's out of their hands and the collection agency can do whatever they want. The collection agency says they can do whatever they want. The insurance company says the same thing, but also that I should hire a lawyer. Hire a lawyer for their error! WHat the..so I respectfully disagree with the previous poster. I have been nothing but nice and polite to everyone I have spoken to. It got me nowhere. And insurance companies have paid huge fines to the state from pulling these type of scams. I do wish you have better luck.

This is the sort of situation that the Insurance Commissioner in my state would be all over and it would save you having to get an attorney, I have seen them do a ton here but I don't know if all states have the same set-up or same powers afforded to an Insurance Commission. If the hospital and insurance company are contracted with each other, the hospital should be taking what the company will pay as payment in full. What a PITA for you. I hope you get a solution worked out soon.

[sste]

strollerqueen, I agree about the state. Also, if that hospital has a contractual r'ship with your insurance they should NOT be allowed to go after you for for additional money.

[gatorsmom]

I'm sorry you are going through this. I agree insurance companies SUCK. I just wanted to add that like Kris said, you need to do a timeline AND YOU NEED TO WRITE EVERYTHING DOWN. Document, document, document. Who you spoke to, on what date, and what they said and what actions were taken or agreed to be taken. It will help you keep it all straight without having to think about it all the time.

I hope this turns out all right for you. I"ll say some prayers. :hug:

[Tondi G]

Ugh, so sorry you have to go through all this. My middle son had a very expensive ear surgery a couple of years ago. It wasn't optional-he had to have a tumor removed that eventually would have killed him. I did everything I was supposed to do, sat down with the hospital's finance dept., paid them a $1,000 deposit, got it all approved through my insurance. Everything was paid, and everything was fine. Or so I thought. A year later, after I had just had a baby and was in the middle of moving, I got a bill from the hospital for 3-grand from the surgery. Nothing was explained. Since I knew everything had been paid, I figured it was an error. The next thing I know, I am getting phone calls and letters from a collection agency for the amount. It took me numerous phone calls to figure out why I was getting the bill, (and when you are moving into a new house and have a new baby you have so much extra free time to sit on hold and get passed around from dept. to dept and place to place) since no one would come out and say it. Apparently the insurance company decided they had overpaid, and made the hospital pay them back. So the hospital then came after me. To add insult to injury, the collection agency has added a huge amount of interest to the debt, starting from the date of the surgery. This, despite the fact that they HAD the money from the insurance company! Now the hospital says it's out of their hands and the collection agency can do whatever they want. The collection agency says they can do whatever they want. The insurance company says the same thing, but also that I should hire a lawyer. Hire a lawyer for their error! WHat the..so I respectfully disagree with the previous poster. I have been nothing but nice and polite to everyone I have spoken to. It got me nowhere. And insurance companies have paid huge fines to the state from pulling these type of scams. I do wish you have better luck.

Thats BS! I'm sorry you are going through all that! Having my son go through 3 broken arms in 2 years... one of which required surgery to repair... I know all too well the calls and letters from collection agencies. Just when we thought one thing was paid and complete we'd get another phone call. We probably paid double on things cause we couldn't keep things straight. It's just a nightmare.

I can't believe they suggested you get a lawyer! The collection agency CAN waive the additional interest etc that they have tacked on. When we had been late paying for the delivery of #2 my DH called the hospital and talked to them... they ended up cutting what we owed in half!!! I have to let my DH handle it cause he can stay cool as a cucumber and sweet and they always help him out. I can't keep my composure like he can... after being passed from one person to the next explaining over and over again... I just get nuts!

Hope you can get it all sorted out!

[Radosti]

So sorry!!! I was in your limbo after DS2 was born. Someone at the hospital clicked the wrong button and indicated that I have secondary insurance. EVERY claim from the hospital and the ob and the pediatrician's offices was declined after that. My delivery, well, everything! They REFUSED to believe that I didn't have secondary insurance. I was a mess. Luckily, no one got sick, but it was still a nightmare. And I have Aetna HMO. So, having an HMO doesn't save you from someone's mistake.

Finally, I convinced them that I don't have anything else. They resubmitted and slowly, very slowly kept re-processing claims. I had collections agencies calling me because it took so long. What a pain that was!!!