Insurance Problems

MsVeryDenseBreasts

Has anyone else had their insurance company outright reject the PS claim for the 2nd stage of their reconstruction process? I specifically spoke to my insurer in advance of the surgery and also have a letter stating I'm eligible for the procedure (even though that step was technically not necessary for out patient surgery under my plan). Because I was having the 2nd surgery a couple of days before the 90 day mark from the 1st surgery, I checked in advance to ensure that would not be a problem. I was told it would not because the 2nd surgery is for a different purpose (different CPT codes etc). Now the insurer is claiming this is part of a "global" bill...another words that they think this is a duplicate of what they already paid the first time and not eligible to be billed separately....and that I'd have to go through a grievance/appeal process to get it reviewed. I cannot tell you how maddening this is. Our insurance process is a joke. Like we need this on top of everything else we are dealing with?!

BethL

This is absurd, and you shouldn't have to deal with this. Have you gone to the biller working with your ps. They are the ones who need to fix this. There are laws protecting us from things like this and it seems whoever submitted the information must have done something wrong.

Ridiculous, it's always something....isn't it?

Golden01

I think it sounds like a problem with the doctor's billing. I'd start there. All group insurance plans have been required to pay for reconstruction and other similar costs following surgery for BC since 1998. My Mother, who is 91, is a really-really good Democrat. She tells that President Biill Clinton signed the law that requires mastectomy bras and prostheses.

Here is some info that might be helpful: http://www.breastcancer.org/treatment/surgery/reco...

MsVeryDenseBreasts

Thanks ladies. Yes, I have a query pending with the PS billing office. The insurance rep I spoke to the other day spoke in circles. She clearly had no ability to explain why the claim was denied. Ya know to boot....they have paid all the other claims associated with this surgery already (hospital etc) and they deny the surgeon's bill?!! Nonsense. They may need to be reminded of the Women's Health Care Act of 1998 that is referred to in the other posting here. This is not the first time I've dealt with this insurance nonsense. Last year they tried to tell me that the ONSITE lab that performed my pathology for a surgical biopsy in an in-network hospital was out of network! That required an escalation to my company's HR dept (to the liaison for insurance carrier negotiations) to get that resolved, and they only did so reluctantly.

calidancer

Absolutely maddening! An insurance delay totally changed my reconstruction result. In the time it took them to get their act together I built up lots of scar tissue and basically lost my good skin envelope.

I finally found a grievances counselor at BS who got everything approved. It took hours on the phone for me and the coordinator at my PS office though. The right hand does not know what the left hand is doing. What a mess. You're right, it's too much on top of the rest of it.

I'm sure you will prevail. Sorry you're going through it though. Grrrr.

ChiSandy

This is so maddening--and an example of just how far the insurance companies will go (and the contortions they will perform) to evade both the 1998 statute and the ACA. Everything started to go downhill when HMOs replaced medically-trained personnel with bean-counters in their Utilization Review depts.--and it spread basically to managed-care plans in general. It’s outrageous that someone with two years of junior college or less (in a non-science field) can have the power to veto the sophisticated medical decisions of physicians & surgeons. I am so glad I finally made it on to Medicare (although even they have arbitrary cutoffs & exclusions--LE compression sleeves are not covered but 2 bras a year are? And PT sessions are capped even if the problem is not resolving or is even worsening).

Until we eliminate the profit motive from health care, it’s only going to get worse. Yes, providers have a right to make a living--but not to make a killing (and I say this as a doctor’s wife). Insurers’ profits keep increasing as benefits shrink and premiums rise. What’s wrong with this picture?

rainnyc

I'm so sorry you're dealing with this. One thing I've found helpful: Whenever I'm on the phone with someone who's talking in circles, I immediately ask to speak with a supervisor.

Keep notes of all conversations and date the notes, so you can say "On January 31, I spoke with ___ who told me XX."

Golden01

While I've had my "go-arounds" with insurance companies, I find many doctor's billing staff don't understand the new coding system and how their work impacts whether claims will be paid for or not. In good offices, it is seamless, in offices where there are disconnects in the practice (left hand not knowing what the right hand is doing) it can be frustrating. I had the insurance company not pay the plastic surgeon for one of my surgeries, I was not getting billing notices but I would check from time to time. I brought it up to the PS, he was totally unaware that he hadn't been paid in over six months and that his office simply needed to send in one piece of information. Problem solved. We had another doctor's visit for my husband denied as "out-of-network", the doctor had been in the network for years. Turns out the billing staff had sent in the claim as "out-of-network". That one took having the insurance company and the billing office on the line at the same time to get it solved as they both kept telling me it was the other that needed to make a change in the paper work. It was the doctor's office that needed to make the correction.

Good luck.