Wellness

[chrystaltree]

Some people are talking about coding as if they actually know what medical coding is.  Op said the claim was denied twice, which means there were two appeals

• A coding review would have been the first thing that was done when the claim was denied.  I'm certified coder and a Health Information Specialist and this was my world before I retired.  The cardiology part denied for no authorization because pacemaker always require preauthorization.  Since I don't what is in the medical record, I can only guess at what might have gone wrong.  It's possible that the patient had a cardiac arrhythmia during the hernia repair and they put in a pacemaker BUT, it was not medically necessary to do it THAT day.  It wasn't a matter of life or death.  They scheduled it after obtaining authorization.  Another scenario is that the patient was known to have an a cardiac  arrhythmia and they decided to insert the patient since the patient was coming in for the hernia surgery anyway.  But they didn't think that the pacemaker needed a separate authorization.  A third scenario is that the patient would have died if they hadn't put the pacemaker in but no one followed the correct procedure in speaking the insurer to advise them of this.  Every insurer has a process to cover this.  Lastly, if the patient had the hernia repair AND the pacemaker but never was admitted as an inpatient. Both procedures were day surgeries....the patient was not critically ill and the pacemaker was elective.  They should have scheduled after it was authorized.   Insurers hold all the cards now and doctors and hospitals have to know the rules and follow them or risk not being paid.  Some things aren't appealable and insurance companies don't give anyone the benefit of the doubt.  Remember what the insurance company calls an "emergency" is very different from what the general public would call an emergency.  You say the claim was denied twice, your friend should call bcbs and ask for the details. Like did the doctor appeal or was it the hospital and what is the next level of appeal.  

[RealtyGal2]

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@ellaphant wrote:

American ' health care' is shameful.

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I am happy to now know all these things because I have Aetna and will be changing that this year. Is anyone recommending their carrier?

[Jo1313]

We have regular Medicare plus we pay for BC/BS supplemental.I have had 6 major surgeries 2 close to death..In 5 and a half years.

Also spent 5 months in the hospital at 1 time and a stint in rehab..to learn how to walk again from being in bed too long...I have never paid anything out of pocket for any of it..just paid my monthly premiums..no co payments or deductables. Same goes for DH no out of pocket..Yes the premiums are a lttle pricey.

Did get 2 bills and they were taken care of..they were coding errors..it does happen.

No amount of premiums in our life times..would come up to the amount of all the bills we could have had.

We do have seperate plans for our scripts..and the scripts still cost quite a bit..besides the premiums.

We don't have dental or eyeglass coverage.

A friend has an advantage plan..not sure which one...She has brain  cancer and they had to do a biopsy..which did something to her nervous system..her advantage plan would not cover any rehab!

[Greeneyedlady21]

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@ellaphant wrote:

American ' health care' is shameful.

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Yes there are plenty of problems with health care in America. But this problem is with the health insurer. The problem is that health insurance companies are allowed to do these things and get away with it. Greed and profit over people.

[CatsyCline]

Make sure you get a hard copy of the claim resolution when they tell you the claim has been taken care of.  Don't rely on a phone call saying yes it's all set or lack of follow-up contact (i.e. "never got a call back"). Get it in WRITING!   And, always follow-up by checking your Explanation of Benefits!   Look at the line which indicates Patient responsibility.

[Trailrun23]

My sister says she should hear back from the surgeon's office again tomorrow. They are appealing it again but had to add more data or something. Only the dr office can provide the data they are asking for now. I am sure we will get it resolved but no one should have to spend so much time and energy to get medical bills paid that insurance owes, not the patient. Almost everyone has a story like this, and that's just wrong! Years ago when I was working, I had to take several days off from work just to get a medical claim resolved. 

[Starpolisher]

A friend of my family's husband went to the ER for what appeared to be a heart attack. They are both in their late eighties. The doctor decided to keep him overnight for Observation.  Of course, they agreed. He was taken to a room on a floor of the hospital. After he came home the next day, they later got a bill for $5,000! They have medicare and some private insurance. They were told the claim was denied because he was only there for observation and was not admitted  to the hospital! What!???

[CelticCrafter]

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@Starpolisher wrote:

A friend of my family's husband went to the ER for what appeared to be a heart attack. They are both in their late eighties. The doctor decided to keep him overnight for Observation.  Of course, they agreed. He was taken to a room on a floor of the hospital. After he came home the next day, they later got a bill for $5,000! They have medicare and some private insurance. They were told the claim was denied because he was only there for observation and was not admitted  to the hospital! What!???

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Yes, it's stated in the Medicare and You book.

[phoenixbrd]

@deeva   This is what I have heard and looked at the statistics which prove it is true.  I would like to revert to original medicare, but then I lose the dental and vision that the Advantage Plan pays for.

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@deeva wrote:

That's one of the problems with Medicare Advantage plans. They deny a lot of necessary procedures. 
I'm dealing with this with my 87 year old aunt. 

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[Trailrun23]

They will come up with any excuse to deny a claim. Shameful.