Wellness

[itsmagic]

@chrystaltree I do understand that the OP said she doesn’t have a PCP. I know that the hospital scheduling that I use doesn’t call my doctor for a referral (even behind the scene) so I was just surprised by her situation.  And I know they don’t do mammograms for free - my insurance has always paid for it.  This is my experience and I based my answer off of that. 

[Mom2Dogs]

@cuddlesmama ...when my primary doctor retired, I was not able to get a new doctor!  I ended up with a NP....if she has any questions/concerns about my care she has a doctor that she works under.  I really like her...

[sann]

I schedule my mammogram. Then the results are sent to my physican. 

[Icegoddess]

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@Jinlei wrote:

Not where I live.  Every year I call the hospital to schedule my mammogram and have no problem.  I never have to give them an order from my doctor.  All they ask is who my doctor is so they can send them a copy of the report.  It has been like this for over 10 years.  I do not understand needing an order as most insurances pay for mammograms 100%.

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Same for me @Jinlei. I actually get a letter from the facility telling me it's time to schedule and I call them up and schedule.  I'm sure I could probably give them my Gynecologist as my doctor instead of my PCP if I wanted.  I wonder if OP has tried that.  

However, @Carmie, I find insurance will still try and find a way out of paying for those things that are supposed to be free under the ACA. Like on Mammograms telling me that although I went to an approved facility, the doctor who read the Mammogram was not In-Network.  I told them I had no control over that and they did end up paying.  But, now, even though I go to an In-network facility for my gynecology stuff, they won't pay for my Pap Smear if they send it out to an out-of-network lab.  They say that is my responsibility to make sure they do.  What it up with that?  I shouldn't be telling my doctor who to send my Pap Smear to.  And How was I supposed to know that in the first place.  And you can only file an appeal; you can't talk to anybody anymore.  

I would be happy to pay for those "freebies" myself and have a much lower than $950/month premium and a $6500 deductible.  Actually, my deductible might even be more than that.  They don't even tell you that info when they send you the letter about how much your insurance premiums are going up.  And I'm a healthy person.  I probably spent all of maybe $500 against my deductible last year.  I know it was up to about $350 in November.  

[meem120]

Of course. That's standard procedure. 

[Carmie]

@Icegoddess   When you have health insurance it is a legal contract.  The benefits must be processed and paid according to the terms and conditions of that contract.

If a provider is in-network, they will be paid according to the network benefits.  If a provider is out-of-network, out-of-network benefits apply.

The insurance company is not trying to get out of paying.  They are following their legal guidelines and obligations...they have to.

If you have no choice and your services are performed by an out-of-network provider...usually the doctor who reads X-rays, labwork or ER physicians, you must write a letter of appeal and usually your claim will pay at the in-network rate under the invisible provider guidelines.  You are not able to call in an appeal...legally it must be done in writing.

There are even some insurance policies that do not have to folllow the mandated freebie benefits.  If your employer is self ensured, they can cover what they want to and exclude anything they want to.

Before your insurance rates can be raised, the insurance company has to get permission from the insurance commission in your state.  The hearings are open to the public.  A person can attend and speak their piece, but not many people do.

It sounds like you have "Obama Care". That is the worse program ever.  It only benefits people who make a hair above the income level for Medicaid.  I can guarantee you that every time our government gets involved with healthcare and insurance, it's going to not end up well.

And  yes, you can request that your doctor send your lab tests to an in-network provider. Often the doctor's double dip and own the lab where they send the specimens.  You do have a choice. That's the law.

[Icegoddess]

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@Carmie wrote:

@Icegoddess   When you have health insurance it is a legal contract.  The benefits must be processed and paid according to the terms and conditions of that contract.

If a provider is in-network, they will be paid according to the network benefits.  If a provider is out-of-network, out-of-network benefits apply.

The insurance company is not trying to get out of paying.  They are following their legal guidelines and obligations...they have to.

If you have no choice and your services are performed by an out-of-network provider...usually the doctor who reads X-rays, labwork or ER physicians, you must write a letter of appeal and usually your claim will pay at the in-network rate under the invisible provider guidelines.  You are not able to call in an appeal...legally it must be done in writing.

There are even some insurance policies that do not have to folllow the mandated freebie benefits.  If your employer is self ensured, they can cover what they want to and exclude anything they want to.

Before your insurance rates can be raised, the insurance company has to get permission from the insurance commission in your state.  The hearings are open to the public.  A person can attend and speak their piece, but not many people do.

It sounds like you have "Obama Care". That is the worse program ever.  It only benefits people who make a hair above the income level for Medicaid.  I can guarantee you that every time our government gets involved with healthcare and insurance, it's going to not end up well.

And  yes, you can request that your doctor send your lab tests to an in-network provider. Often the doctor's double dip and own the lab where they send the specimens.  You do have a choice. That's the law.

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@Carmie I did file an appeal and they denied it.  And now I know to tell them where to send my specimen, but it was a huge surprise.  And who would think to check that sort of thing when going to an In-Network doctor?  But, I still think the Insurance Companies word those contracts in such a way that they can easily find a way out of paying for a service.  Yes, I have ObamaCare.  That is my only choice.  The state Capital is several hours away, so even if I did know when that hearing was I wouldn't be ale to go.  

I suppose, if we had our mortgage paid off and no car payments, we could control our "income" such that I could get a lower premium like my "friend" who accused me of lying about how much I was paying.  I know he's got to be gaming the system like that since I know where he used to work and what level of income that job demands.  Hubby is on Medicare, so that $950/month is just for me.

I have actually considered dropping my insurance since there is no longer a penalty and I would save a bucket-load of money.  But, then there's that unforseen car crash, skiing accident, or some high-dollar disease.  But, still, it's quite tempting.  

[Carmie]

@Icegoddess  Insurance companies do not word things to get out of paying for services.  Your benefits are listed clearly.

You are responsible for knowing those benefits, and you alone.  You should call the insurance company and ask before you receive services so you don't get any surprises.

[Icegoddess]

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@Carmie wrote:

@Icegoddess  Insurance companies do not word things to get out of paying for services.  Your benefits are listed clearly.

You are responsible for knowing those benefits, and you alone.  You should call the insurance company and ask before you receive services so you don't get any surprises.

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We'll just have to agree to disagree.  You shouldn't have to jump through a bunch of hoops just to go to the doctor and get basic medical care.  For an insusrance company to not pay for a mammogram because the doctor who read the mammogram is out-of-network is just ridiculous.  

Instead, maybe it should be a requirement that the doctor's office/facility send specimens/radiographs/etc to an in-network lab/doctor to be considered an in-network doctor.  

[Carmie]

w@Icegoddess   First, a mammogram would not be denied because the doctor who reading it was out-of-network if the mammogram was done by an in-network provider.

All out-of-Network claims will be processed according to the terms of your contract.  I am guessing that the claim for the reading either applied to a deductible or paid at a reduced rate and the provider did not accept the payment made and is balance billing.  

If you have an HMO is could have just flat out denied because you went out-of-Network.

When you appealed, did you complain about the denial/deductible and write that it wasn't fair and you paid a lot of money for this coverage and it should have been paid?

That is not the type of appeal you needed to write.  An appeal to overturn the processing of a claim needs to state why the claim should be reconsidered.  

The appeal should have stated that you choose an in-network provider and that provider sent the claim to a provider that you didn't know about, didn't choose and never saw,  This type of provider is called invisible or ghost provider. 

Most policies have a provision to cover ghost providers. In many areas of the country, there could be a lack of in-network providers for some services.

if your first appeal is denied, they should have given you a reason why?  My guess is that  they said you claim processed correctly according to your benefits.

You could have written a second appeal...if your time for writing this hasn't run out..appeal again using the ghost provider excuse.  If your coverage has a provision for this, they will approve your appeal.

I agree this is a pain in the neck.  It is so much easier to just ask the doctor to send your  " medical stuff" to an in-network provider and even have a copy of  providers and labs with you to show them or tell them exactly who you want to do your medical readings and diagnostics.

My husband had a service last July.  The insurance denied a claim for $18.75.  I fought that claim and it was finally paid at the beginning of December.  It wasn't the money, it was the principle.

I worked in health care  for a little over 25 years and in that time I worked many years in the appeals unit. I am not trying to be snarky or mean.  I am trying to help you so that this doesn't happen to you again.

Many, many times I have had to deny a person's appeal and felt so bad.  I would write the legally required letter, then call them up and explain how this could be avoided or advised them to reword the letter and appeal again.

I wish you a healthy year and no more health insurance issues.