Insurance denied overnight stay after exchange

sweetbean

Hi everyone,

I stayed overnight after my exchange because I was in the recovery room until 10:30pm and I live over two hours away from my hospital.  I thought that my PS's office had cleared it with my insurance, but I guess not.  Now they are denying covering that stay.  What are my options?  I'm freaking out - almost in tears.  I can't pay for an overnight stay at Columbia.   

my insurance is saying that I did not have any of the following: 1) a need for hospital care for a disease or condition 2.) problems during or after surgerey or procedure requiring hospital care 3.)a high chance of having a bad reastion or problems due to anesthesia or other drugs used. 4.) that care in the hospital as an inpatient was needed due to other problems that made it unsafe to go to another level of care.

 Help! 

Anonymous

sweetbean- So sorry you're having to deal with insurance issues on top of everything else.  It's so frustrating!  I think insurance companies are in the mode of just automatically denying claims whenever they can.  I would try to get your doctor to document why they thought it was in your best interest to spend the night and then file an appeal with your insurance company and include this documentation.  Was your surgery originally scheduled for earlier in the day, and it got delayed, forcing you to stay later?  If so I would document this as well.  It may take several attempts, unfortunately, but sometimes you can get your insurance company to reverse their decision.  If that doesn't work you can also get the hospital to reduce your bill.  (Something most people don't know about.)  Someone should have explained to you that staying the extra night was not going to be covered.  (Had you known you probably would have opted for a cab and a hotel.)  Talk to your doctor, though, or whoever made the decision to admit you.  Someone was responsible and they will be your best ally through this.  Good luck with everything.  

christina0001

Does your insurance company offer you any right to appeal the decision?

sweetbean

Yes, I have 180 days to appeal to the insurance company.  My anesthesiologist has already responded to my e-mail (he's awesome) and said to give him a call on Monday.  So I think he will help me out.  I had massive pain issues following my BMX, so nobody wanted me to leave so late at night, because they wanted to make sure my pain was managed.  We actually had a hotel room booked, but I stayed overnight instead.  Right now, I am wishing that I had just hauled myself up and gone to the hotel room.  However, all the doctors and nurses really felt I should stay.  I'm hoping that they can re-code and re-submit and make this go away.  I can also appeal to the hospital board, I think, if the insurance won't budge.

ma111

If you were in the recovery room until 10:30 pm, isn't that problems with anesthesia? Your PS office should help you clear this up.

shore1

Sweetbean, the hospital can re-submit your claim with info supporting the stay within the appeals period. Sorry you are dealing with this, but I bet the hospital can help you clear this up. Let us know how it works out.

mrsnjband

Maybe you doctors could have the overnight post certified.  They had to do that with a Chest ct my HD had.  You could have a pelvic, abdomin ct and not have to be precert but Chest ct needed a precert.  It's worth a try. NJ

sweetbean

Yes, the PS's office was supposed to precert this stay.  I'll ask them about that as well. Thanks!

Golden01

So sorry you are having insurance problems while you are working at getting better. I bet, come Monday, your PS office will be able to sort it out for you. I got to the surgery center for my TE exchange and the woman in admitting insisted I had no preauthorization. I took a deep breath and asked that they wait until 9 am when the PS office would open and I thought it could be cleared up. It was. They had authorized for me to stay overnight (and I did) because I've had problems with low blood pressure after each surgery. Insurance folks don't work on the weekend, I hope you can set the worries aside until Monday morning. Positive thoughts are coming your way!

dogeyed

Sweetbean, long time ago, gosh it's been 30 years, I had an issue with a mole that had to be removed because I injured it by accident and it was bleeding all over the place.  Insurance wouldn't pay for it, so I picked up the phone, and I 'splained to the lady what happened, and she realized it was not an "elective" surgery.  It was forthwith taken care of.  Also, just 5 years ago, I was trying to get disability, and the people had made an error, and I talked to the head of the case review department and told them this, and he directed me to apply again, and within a couple weeks, I got my disability.

Methinks your insurance people somehow don't know about the connection your most recent surgery is with your breast cancer, and also the late hour in recovery, the pain issue you brought up, and now you'll have your anesthesiologist doc help you out on this, too.  I think after you talk to the rads doc, while it's possible everyone will have to mail in an appeal, it's also possible if you ask your anesthes doc if you can have your insurance company call him, THEN you can pick up phone and tell insurance this this was breast reconstructive surgery, etc. etc., and if all else fails, that you have your anesthesiologist's phone number if they need to call him, too.

But I think you should indeed actually call the insurance people today after you talk to anesthes, and tell them by law they are to provide you with breast reconstruction needs, not to mention the other items, and you SHOULD get a positive response and that will put you well on the road to them taking care of it.  GG 

sweetbean

Thanks!  I'm actually feeling pretty confident that I can get this covered.  I had severe pain issues after my BMX - by which I mean the paravertebral block failed, but that wasn't apparent until the middle of the night when the pain meds and anesthesia wore off.  There I was, at 12am in the hospital, but the nurses refused to give me any pain meds because the overnight doctor wouldn't order it.  They left me there until 7am, when the surgeons started doing their rounds.  Can you imagine - no pain meds at all for that long?  By the time the docs got there, I was frozen to the bed in pain, unable to move even an 1/8 of an inch.  It was epically uncool.  

Anyway, due to those issues, I think I have a case for staying over for observation.  Nobody, but nobody, wanted me to leave that hospital until they were SURE that my pain was being managed this time. 

dogeyed

Sweetbean,  Yah, and it's really not so much the pain issue as it is that this was part of your breast reconstruction steps, which women for years fought hard to get that included in insurance coverage, so women had the choice to get replacement boobs!  I don't see how the insurance people could have missed that, but believe you me, they DO miss stuff, as per my examples.  Not only that, I don't know too many hospitals that would discharge a woman after 10:30 p.m. at night, for crying out loud, which that, combined with the pain problems you had after your last visit there, will seal the deal.  Let us know how things go if you make some calls today!  GG

lhasamom

I had the same thing happen to me, I had a BAD infection with the TE and my ps took one look and told me he was admitting me to the hospital.  Long story short, I was in there for 6 days, under IV meds, had 300 cc of fluid removed from the infected breast and had cultures done.  Oh, and I also had MRSA!  Got the bill and it said the bill was denied, because it wasn't pre authorized, not medically NECCESSARY for me to stay overnight, etc...  I totally freaked out!  When I showed my PS the letter, he got PISSED!  When we were in the exam room he whipped out his cell phone,called the head doctor of the claims department, requested that the call be recorded, and then for the next 10 minutes, he reamed this guy a new one!  When he hung up, he said one word....ASSHOLES!!!  After submitting a DETAILED letter to the grievance comittee, explaining why I couldn't get pre authorization, etc.I finally did get the hospital stay covered, $8,968.54!!!  I did have to pay $250.00 for a room charge though. 

The one thing I learned was to make sure EVERYTHING, no matter how small, was authorized beforehand.  Even though on that form it states, this doesn't mean it Will be covered, it has been for me.  I think there is a special place in hell for insurace companies.  They sure deserve their own wing!!!!  Keep us posted on the outcome!!!!

peggy_j

Can your surgeon's staff go to bat for you? Usually they know the magic words to say to get pre-approval (or post-approval, in this case). If that doesn't work, see if there is a consumer-advocacy board for health insurance. There's one in CA (found the info on a *.gov website) and when I called the guy was great--surprisingly knowledgable and helpful.