Seriously insurance???

[MSWR0319]

I just got the bill for DS's penis surgery a month ago. Apparently our insurance doesn't think it's necessary for anesthesia because the EOB says they are not paying it because it's not medically necessary for this procedure. Ugh, really??? I really hope I get a male representative when I call about it this afternoon because I plan on asking him if he'd like to have his scrotum moved and his penis straightened, and then be circumcised with no anesthetic. What do they want them to do? Give him some advil?

[trcy]

Omg! I hope that is a mistake!

[lizzywednesday]

It sounds as if someone may have mis-coded the procedure when they submitted the claim so it's listing as a simpler procedure than it is.

I would be just as mad as you and on the phone with everyone and their brother to get it resolved. It's stressful enough letting your baby go into surgery (I should know - I've done it 3 times!) but then you need to worry about this?

[Staraglimmer]

Surely that was coded incorrectly? That's crazy.

[BabbyO]

WHAATTT???? That is crazy! Can I join your b!tch? I have to call our insurance to get an exception for a prescription. If we have the same prescription filled x (I think 3 times) in a year (that isn't antibiotics) we get a nasty gram and threatened with the insurance NOT paying any of the cost. They want us to use the mail-order service (that is beyond difficult to work with if it is anything other than a maintenance med).

So Stachio needs an emergency inhaler. The Dr. won't prescribe a 90 day supply (typically required for mail order) because it is too much to have around the house. So I call the mail order place and they tell me that they can do a 30 day supply, but it will cost more than if I get it retail! Gah! It's not a maintenance med, but it isn't an antibiotic....they don't know what to do, but they certainly aren't helping me, it isn't more convenient for me, and it isn't more cost effective for me. Insurance is such a PITA!

I really hope you do get a male when you call about it. Hopefully whomever you speak with will have some common sense! But really, how is that a procedure that would not need Anesthesia - ever?

[Corie]

That is the craziest thing I've ever heard!!! When you call, I would keep transferring customer service reps until you get a male.

[liz]

wow OP, that's crazy!! Hopefully the rep on the phone will realize how foolish the bill is and help take care of it right away.

[MSWR0319]

So it was not coded incorrectly. When I called and explained that I had just received an EOB that denied the claim the rep goes "WHAT?!?!?!" She was the most personable, friendly insurance rep I have ever talked with. So at least I didn't have someone rude. They denied it because apparently they don't think that's the proper anesthetic to be using for this procedure. I'm still puzzled as to what exactly they were wanting them to use. So now I need to call the hospital to figure out who I call for the anesthesia's billing dept so they can send a letter of medical necessity in hopes that they "might" approve it.

[MSWR0319]

WHAATTT???? That is crazy! Can I join your b!tch? I have to call our insurance to get an exception for a prescription. If we have the same prescription filled x (I think 3 times) in a year (that isn't antibiotics) we get a nasty gram and threatened with the insurance NOT paying any of the cost. They want us to use the mail-order service (that is beyond difficult to work with if it is anything other than a maintenance med).

So Stachio needs an emergency inhaler. The Dr. won't prescribe a 90 day supply (typically required for mail order) because it is too much to have around the house. So I call the mail order place and they tell me that they can do a 30 day supply, but it will cost more than if I get it retail! Gah! It's not a maintenance med, but it isn't an antibiotic....they don't know what to do, but they certainly aren't helping me, it isn't more convenient for me, and it isn't more cost effective for me. Insurance is such a PITA!

I really hope you do get a male when you call about it. Hopefully whomever you speak with will have some common sense! But really, how is that a procedure that would not need Anesthesia - ever?

That is totally annoying!! Sometimes I just don't get insurance. Luckily my first job was in a prosthetic office so I learned a lot about billing/coding/insurance even though I was the accountant. Our insurance will cover immunizations at 100% if we go in network. So they will pay the dr's office over $200/shot, but will only reimburse me $6 if I go to the local health department (which I prefer to do because the nurses are much better) for a $10 shot. I just don't get why they will waste all that money when I prefer to go to someplace much, much cheaper.

[MSWR0319]

That is the craziest thing I've ever heard!!! When you call, I would keep transferring customer service reps until you get a male.

I just read this. Totally should have done that!!

And I just found the multiquote button on this new format as I"m typing this. Sorry for all the single quote posts!

[crl]

Wow, that totally sucks. Medical insurance is so Byzantine. It is just the most ridiculous set up ever. I hope you get it all straightened out without too much difficulty.

Catherine

[randomkid]

So it was not coded incorrectly. When I called and explained that I had just received an EOB that denied the claim the rep goes "WHAT?!?!?!" She was the most personable, friendly insurance rep I have ever talked with. So at least I didn't have someone rude. They denied it because apparently they don't think that's the proper anesthetic to be using for this procedure. I'm still puzzled as to what exactly they were wanting them to use. So now I need to call the hospital to figure out who I call for the anesthesia's billing dept so they can send a letter of medical necessity in hopes that they "might" approve it.

This is ridiculous! It's up to the anesthesiologist, not the insurance company, to determine which anesthetic is most appropriate for the patient. I'm sure the anesthesiologist had a good reason for using the drug he/she did! It's because people who are not medically trained are making the decisions at insurance companies. They have no idea what they are doing, they just "go by the book" they are given to make these determinations. Can't wait to see what happens when the IRS is managing healthcare - ugh!

[katerinasmom]

I completely understand your frustration. After giving birth to my second, the varicose veins in my right leg were unbearable and I had laser surgery to correct them. The insurance company covered the cost of the anesthesia but not the surgery. I called and asked why they were approve one and not the other. They said that I had not shown the surgery was medically necessary. But the anesthesia was medically necessary? Noone thinks anymore - everything is a machine issued response. I had to spend hours getting the surgery approved and had to get two different doctors to submit reports substantiating the medical necessity of the surgery. Eventually it was paid but not without aggravation. I asked afterwards if I could get some more anesthesia to put me out of my insurance hell misery since it was apparently medically necessary and covered by the insurance.

[ahisma]

First off - that's nuts.

Any news on their determination? If not, I'd ask them to formally submit it to their appeals process, that should take 30 days. At the same time, ask them for the contacts for 3 of their external review firms so that you can select one and be ready to get the ball rolling if their internal appeal process still rejects it. That should light a fire under them:)

[Still-in-Shock]

Frankly, I would be tempted to call a consumer protection agency. If we have a boy, the circumcision will be done according to Jewish tradition, but the doctor who does it HIGHLY recommends anesthesia. He has done over 10,000 circumcisions, so he knows what he is talking about. http://cybermintz.com:9080/ispainfull.html

Unfortunately, a protest might take a long time, and still get you no where. That's what happened when I had a D&C after one of my miscarriages. Insurance wouldn't pay the anesthesiologist. We eventually gave up and paid out of pocket, just to put that chapter behind us.