Wellness

[Goodie2shoes]

 Back in January I posted  here about a denial for a blood clot prevention machine that I received post knee replacement in Sept of 2019.  The insurance company said it was not a covered benefit which made no sense to me.  I was billed and paid the provider  for the equiptment. I contacted my doctor's office to discuss the denial and they agreed to appeal the denial to my insurance company. Yesterday I received a letter from the insurance company advising the equiptment was denied based on the billing code but has now been reversed because the correct code was provided so they will pay and I will get my money back. I just wanted to post an update and advise anyone who may run into this type of problem to follow thru with your doctor's office and the insurance company if you feel the denial was incorrect. 

[hckynut]

@Goodie2shoes 

My wife worked most of her career as a Medical Claims Analyst, and several as the same in Dental. She was a higher level for many years and her job was reviewing claims,  cleared by other analysts, before they were paid or denied.

These analysts are trained for that specific job. I was shocked at the number of "analysts" made coding mistakes on different types of claims. That gave me "pause to think" how easily a lower in knowledge doctors office worker could make a "coding mistake". Unfortunately it is not uncommon for many mistakes are made.

I can't begin to tell you how many thousands of $$$$ of coding mistakes that were made on my humongous stack of EOB's from my medical insurers. I know a bit more than average about insurance now, but my wife saved us from a ton of mistakes made in coding.

Happy to hear you will be getting your money returned, as it should be. Hope you are doing well

hckynut 🏒

[Goodie2shoes]

@hckynut 

 Thanks for your feedback. I am a retired nurse and worked for an insurance company doing medical management and as a work comp nurse for many years so I had some experience with billing codes. There are so many codes out there and I wondered if that was the issue. I am just glad it turned out in mu favor ! Another stimulus check ! I am doing fine with my recovery, back to normal for the most part and my knee tells me when it's going to rain. Have a great day !

[ciao_bella]

@Goodie2shoes 

I think I know exactly what machine you're speaking about.   It's called the Continuous Passive Motion machine, and it's used to move your leg to prevent blood clots and exercise the joint after knee replacement.  

I had this machine after my first knee replacement and it was covered by my insurance company.  A year after my first knee replacement, I had the other knee replaced.  Same doctor, same everything, except when I was released by the hospital the person giving me the machine to take home to use per doctor's request, I was told it was not covered under insurance.  I had not changed my insurance and everything was exactly the same as the first surgery.  I was told I would have to pay 'up front' with a check before I was given the machine.  If I recall, it was around $350-$400.  I did pay for it because I found it very helpful with my knee replacement. 

I called the insurance company and questioned why it was covered the first time and not the second time .  I was told it wasn't considered 'necessary.'  I fought it and won!  So, you are correct.  Don't automatically dismiss a claim that doesn't go in your favor.   Many times, I believe, insurance companies bank on people accepting their denial of services or claims.  

[Drythe]

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@Goodie2shoes wrote:

 Back in January I posted  here about a denial for a blood clot prevention machine that I received post knee replacement in Sept of 2019.  The insurance company said it was not a covered benefit which made no sense to me.  I was billed and paid the provider  for the equiptment. I contacted my doctor's office to discuss the denial and they agreed to appeal the denial to my insurance company. Yesterday I received a letter from the insurance company advising the equiptment was denied based on the billing code but has now been reversed because the correct code was provided so they will pay and I will get my money back. I just wanted to post an update and advise anyone who may run into this type of problem to follow thru with your doctor's office and the insurance company if you feel the denial was incorrect. 

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@Goodie2shoes 

I remember your post well, glad you were tough / smart enough to stick it out.  So many people are so buffaloed, confused, or scared of the system that they just give up.  

Just had a feeling you would get it resolved.  

Thanks for letting us know.

[hckynut]

 @Drythe 

I agree with everything you've said in your latest post. I will add this. Many are also unwilling to spend the time/don't possess the patience to spend, sometimes hours, to get to the rightful conclusion.

Can't tell you how many times my wife has asked me to talk with different people about things that are just plain not right. Patience and persistence are not her strong suits. Me? The number of $$$ don't matter to me, it is getting to what I know to be the right conclusion.

Stay safe and well now,

hckynut🏒

[RedTop]

I am very surprised the insurance denial was on a CPM! This machine is so important in gently bending the knee to help regain bend and flex movement after surgery. My ortho surgeon stressed the importance of using this machine to prepare for physical therapy.