Had MRI after diagnosis - insurance won't pay

fred009

I hope I'm posting this in the right place.  I was diagnosed with DCIS in June and the BS sent me for an MRI.  I just assumed that since the BS ordered it my insurance would cover it.  Now they are saying the MRI was "investigative" and they won't pay for it.  Has anyone had this happen and successfully appeal it?  Thanks for any advice!

Margie 

sewingnut

Hi Margie,

Why didn't your BS prior auth your MRI?  Why didn't the facility prior auth your MRI?  These are the questions I would be asking your Insurance company.  There should be safeguards in place by at least the facility to know what needs to authorized. Most MRI's need to be.  I would write an appeal letter to the appeals dept. of your insurance company.  State the facts and what you would like to be done. Explain that the MRI would show the extent of the DCIS and would help with your care plan.  There are usually several levels of appeals you can go through.  Just keep both the facility and BS in the loop so they know what is going on.  Good luck.....joann

cycle-path

Margie, sewingnut is completely correct that it's the job of your BS or the MRI facility to get pre-approval. Contact them and find out what they did. Shame on them if they didn't get pre-approval. If they didn't, find new providers.

Chickadee

Insurance companies and the billing departments of hospitals/Doctors offices make egregious billing errors alllllllllll the time.  Your bill may have been coded incorrectly. 

Unfortunately what that means is that we have to expend much energy and stress making them review their mess and correct their errors.  I learned a long time ago to ignore hospital bills for several months when I found them sending me follow up bills with the same procedure and different $$$ outcomes until finally the bill either got to zero or to the co-pay I knew was correct.  Do you have a copy of your plan and what it covers? Sometimes that can be found on the insurance companies website.  That will help you get to the bottom of what should have been covered or not.

peggy_j

WTF, "investigative"? Outrageous. FWIW, my MRI center wouldn't even book an appt. without prior insurance authorization. (it took a week). This happened for my breast-MRI and also when I had an (unrelated) brain MRI about 5 years ago.  Doesn't your BS know how to write these things to get them approved? I thought getting an MRI post-DX and prior to surgery was standard treatment (if there's any possibility of more tumors, you want to know that before surgery). I agree. Ask you BS to go to bat for you and/or the MRI dept. to resub the paperwork. Sorry you're going through this.

Fearless_One

Margie, did you get an actual bill yet?   If so, was the bill from the MRI facility or from the insurance company?  

My hospital won't touch someone without ins authorization for an MRI - sounds strange, like there was a billing screw up.  

cycle-path

It may be a California thing, but I find that if one is about to undergo an expensive procedure for which authorization hasn't yet been received, one is generally given a form to sign that says you understand that your insurance co may not approve or pay for the procedure.

Lisa75

I was blindsided by my out of pocket for the MRI. I was so used to the $35 copays that being told $300 as I sat down for the paperwork that day took me for a loop. they let pay just $200 for now. now I have to make sure of how much the mastecomy is covered.