Insurance Co. denying overnight stay after MX

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janiceg415
janiceg415 Member Posts: 144
edited June 2014 in Employment, Insurance, and Other Financial Issues
Insurance Co. denying overnight stay after MX
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  • janiceg415
    janiceg415 Member Posts: 144
    edited October 2012

    My employer's insurance BCBS of MN is denying my one overnight stay as not medically necessary.  So the outpatient clinic is either asking me for the $2000 plus payment or I have to tackle the insurance company with an appeal.  The clinic did forward both of the doctors surgery notes, but that apparently was not enough. 

    Before having my MX, my doctor told me that I would stay overnight in the outpatient after-surgery suite not the hospital.  She said that she didn't like her patients going home the first night with the drains, etc.  I can barely even remember that night so I don't know how they could think I should have gone home.  I do remember it took me along time to come out of anesthesia. 

    I have contacted my breast surgeon for a letter stating that she felt it was medically necessary but haven't received anything from her yet.  What do these insurance companies want from us?  I always love it when you call for a prior authorization but then they say they can't guarantee payment.  What can the guarantee us, nothing but grief at a time when none of us can stand it. 

    Have any of you had this happen to you?  And what did you do about it? 

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  • marywh
    marywh Member Posts: 2,280
    edited October 2012

    My suggestion is to try and have the surgery done in the hospital and not the outpatient sevices. It may work out to your advantage. My situation wasnt exactly like yours,as I was on a grant and they wouldnt   use out patient services (go figure), but its worth a shot.

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  • Cindyl
    Cindyl Member Posts: 1,194
    edited October 2012

    Mary, I belive the surgury has already happened, right?  My insurance company is a bearcat about pre-approvals.  Before I go in for anything, I contact the insurance person at the facility where the procedure will be done and inquire about pre-approvals.  I don't go under unless pre-auths are all in place.    It's a shame that we need to deal with this stuff.

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  • marywh
    marywh Member Posts: 2,280
    edited October 2012

    ah.. sorry my mistake.

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  • peggy_j
    peggy_j Member Posts: 1,700
    edited October 2012

    Outrageous that this wasn't covered. I would appeal. In CA we also can do an external appeal (someone outside the insurance company). If that fails, why not see if there are cancer support groups that could help. Heck, since this is Pink-month you could always do your own BC awareness and contact the local news station about this crummy coverage. This stinks.

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  • janiceg415
    janiceg415 Member Posts: 144
    edited October 2012

    marywh

    I wasn't given an option to have MX done at hospital as apparently they felt it could be done in their outpatient surgery center, however they do have 2 overnight suites for those they feel should stay.  So that is what I did, not because I demanded it, the surgeon said she didn't like to send patients home the day of surgery with drains, etc.,

    So I am waiting to hopefully get a letter from the doctor saying she felt it medically necessary to stay for what ever reason, like I said I was pretty much out after general anesthesia, and wasn't really with it until the night.  I don't say that I often see people being released at night or after midnight.  I left before 10 am the next day. 

    Cindyl   I thought I had all things preapproved before hand or atleast that is what they tell you when you ask

      peggyi   AND yes I will have to appeal it.  Isn't it a shame that they (the insurance companies) make those who are  undergoing these horrific situations deal with yet another stressor in our cancer drama. 

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  • Andrea623
    Andrea623 Member Posts: 959
    edited October 2012

    I'm so sorry you have to deal with this on top of everything else. I had a bmx, prophylactic on the left side, in early September and my insurance denied the claim for my left side because there wasn't any cancer in it. My surgeon called the insurance company to appeal and got them to approve it.



    I can understand how dismaying this has been for you, and hope your appeal goes through.

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  • Mardibra
    Mardibra Member Posts: 1,111
    edited October 2012

    I stayed one night in the hospital.  I WISH I could have gone home but doc said no.  They woke me up every 45 minutes checking my vitals, they gave me a morphine pain pump (didnt end up needing it), had those auto compression things on my lower legs to prevent blood clots, etc.  Im pretty sure all of that was necessary.  Obviously, that could not have been done at home.   Sounds like your insurance company is focusing on the words "out patient".  Appeal!  

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  • Chrisrenee77
    Chrisrenee77 Member Posts: 1,032
    edited October 2012

    janiceg415,

    Coming from the medical background, the reason why they won't keep you overnight is because the insurance companies do NOT consider it an overnight stay and process. I was very fortunate that my hospital that I work at has what we call "outpatient in a bed", which means you are not technically in the hospital. It's the same way it is about the TE's, not medically necessary for inpatient status, but you are still knocked out, and cut on.  I know it's not an explanation, but that's the way the insurance companies look at it.

    Good luck,

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  • cinnamonsmiles
    cinnamonsmiles Member Posts: 779
    edited October 2012

    Maybe you could ask  your surgeon to help describe how long it took you to come out of the anesthesia (it takes me a good two to three days to totally come out of it and the first 24 hours I am pretty bad), how it affected you and that it was medically not safe to release you home in that condition?

    Your surgeon needs to come up with a different way to help you out.

    I am getting pain treatments through an IV infusion. I was told that Medicare will pay for the lidocaine itself, but not the $440 it costs to administer it!!! 

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  • markat
    markat Member Posts: 909
    edited October 2012

    My BMX was considered outpatient with a classification of being monitored, or something like that. I was actually in the hospital for 2 nights but never admitted as "inpatient". Maybe you could speak with the surgery center to fix how they billed or coded your surgery.

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  • jacee
    jacee Member Posts: 1,384
    edited October 2012

    My 2nd stage DIEP surgery was considered outpatient as long as I wasn't in the hospital more than 23 hours. They start calculating the time safer you wake up in recovery. So I stayed overnight, but it was considered outpatient....yes check the coding your Dr. Used. I have BCBS.

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  • Jomama2
    Jomama2 Member Posts: 96
    edited October 2012

    Please fight the insurance company...this sounds like what is called a "drive-through mastectomy".  If you Google that term, you will find several references to legislation that has been languishing for years.  I thought that "The Breast Cancer Patient Protection Act" was supposed to solve the problem of insurance companies not paying for inpatient bc operations. There has been some discussion in the past on this forum about whether or not the legislation is an urban myth or not.  I am unable to get on Snopes.com to get confirmation (due to filters on my work computer) but perhaps someone with more political/law savvy can enlighten us in this area.

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