Use your State Insurance Commissioner's office!

Good info. Glad it worked out in your favor!

Vinrph- thanks for this post. I have had some issues in the past with getting things paid through my insurance (most genetics testing, two finally got paid through multiple appeals and one denied because the BS office did NOT get the prior approvals for an out of network lab).

I may have a new battle on my hands with some audits that were being done on my initial bc treatment claims in 2012-2013. I got two letters from the insurance company last fall about them auditing two of my claims from my surgery and now they have come back and said they are not paying the imaging center claim and seeking a refund. My guess is the surgery bill audit will go down the same path. And who knows if this is the tip of the iceberg?

I have always kept very good documentation around my medical care (huge file around my care, copies of approvals and EOBs, records of conversations). I will be ready if this becomes a fight. I will be seeing my BS this Friday for a six month check up, and plan to go in with all these denials and to talk to them about what is happening. I am not sure where the root problem is, but find it amazing the insurance company can come back two years plus after treatment and say "we changed our minds, we are not paying for it after all." I don't know if that puts me on the hook to pay for this care but am worried. You know, you are the final guarantor on the account and all. I will start with the place this all began but will leverage the state insurance commission if this becomes an problem.

Hard enough to go through this stuff, never mind not have things paid or payment decisions reversed! Be aware folks!

Very valuable information. I called my State Commissioner's office about a denial for payment due to not getting pre-approval for an out of network lab and the decision was reversed. I had to pay a co-pay that I would not pay for an in network lab, but instead of 947.00, I had to pay 20% of that...huge difference. I had to take it to the State to get this settled though. It works!

AND I love that they (the insurance companies) treat everyone as if they are a drug addict. Just this month mine unilaterally decided that the quantity of pills dispensed shall not exceed X number. They didn't say dosage, they said quantity which forced my physician and pharmacist to adjust the dosage so as to satisfy the arbitrary number of pills. Unfortunately by adjusting the dosage, I am suffering more pain because I don't need the higher amount in one shot - I'd rather it were spread out over the course of the day. I may call my Department of Commerce which governs Insurance in my state.

Amy

Absolutely! Your State Insurance Commissioner is there to help you! I had a terrible time with my doctor's business office. She is associated with one of the biggest hospital systems in the Southeast. Interestingly, they were willing to take my insurance's negotiated rate for all my office visits, so the doctor was paid at 100%. However, they had different rules for the chemo portion, for some reason. They waited about 9 months and then started dunning me for money--over $93,000 worth of chemo. This was on top of the payment they had already accepted from my insurance. I absolutely refused to pay this! I do not understand how a hospital system which has negotiated a contract with an insurance company can then change their rules and balance bill. I live in a very competitive healthcare market. NO OTHER HOSPITAL SYSTEM has ever tried to do this to me. After going around and around with both the insurance AND the hospital billing office for 5 months, I submitted two complaints to the State Insurance Commissioner, along with all the copious notes I had taken with every phone call. Two weeks later, those bills had miraculously vanished.

Now, I'm getting additional bills from an office visit in November. Erg! That's it! I'll pay the damn bill but I have decided to leave my beloved MO because I can't keep going through this~

Thanks for the thread. My insurance company is refusing to pay any of the cost for my yearly preventative Mammogram. Due to the BC last year my provider is required to code it as "diagnostic" and the Insurance company says if it's not coded as 'screening' they don't have to pay any of it. I did find a State Mandate on Insurance on line for my state and it includes the verbiage that the preventative part of the insurance coverage has to include both diagnostic and screening if there has not been any other mammograms within the prior year. I wasn't sure who to contact in the state to get the help I am going to need to appeal this - so finding this is very helpful.

Wish me luck and thanks for the info.

Does anyone know if calling the State Insurance Commissioner is valid for single-payer insurance only or employer-sponsored insurance as well? I know employer plans are governed by ERISA so a lot of state protections don't apply. But I'm having insurance issues as well so think anything that doesn't cost me can't hurt.