[Clutz]

Hi,

I have health care coverage from Medica Essential. According to my benefits guide, I am entitled to 100% coverage for Lab Work and Diagnostic Imaging. Back in March I was referred by a physician at my home clinic (which is in network) to an Ear / Nose / Throat surgeon because I was having difficulty hearing in my one ear. The ENT I was referred to is also in my network. During the course of one of the exams, my ENT decided it was necessary for me to have a CT-Scan. He referred me for a CT scan to a Radiological Clinic which is also in my network. Before sending me for the CT scan, he sent in a formal request to my insurance provider to get pre-approval for the CT scan, and I was approved. On the day of my appointment, I went in for my scan. I believe I made a $10 copay at the time, but was not told that I would be responsible for paying for any other portion of the scan.

Now, several weeks later I've received a bill from the Radiological Clinic for about 60% of the cost of the scan, and my statement from Medica says that I've used up the exact same number of dollars for my out of network deductible.

I shouldn't be paying anything for this service- it's supposed to be 100% coverage for in network Lab and Diagnostics. This was at an in-network Radiological clinic, referred to by an in-network ENT, referred to by a in-network family clinic.

What do I do? How do I fight this?

 

[Happy Camper]

Welcome to the world of small business.

Take it to your companies medical benefits representative with all pertinent paperwork backing your understanding of the claim. If the company gets involved on your behalf, it will save you much run around and stress that the Ins. company will put you through.

 

[ecclesand]

Quote:

Originally Posted by Clutz /img/forum/go_quote.gif Hi, I have health care coverage from Medica Essential. According to my benefits guide, I am entitled to 100% coverage for Lab Work and Diagnostic Imaging. Back in March I was referred by a physician at my home clinic (which is in network) to an Ear / Nose / Throat surgeon because I was having difficulty hearing in my one ear. The ENT I was referred to is also in my network. During the course of one of the exams, my ENT decided it was necessary for me to have a CT-Scan. He referred me for a CT scan to a Radiological Clinic which is also in my network. Before sending me for the CT scan, he sent in a formal request to my insurance provider to get pre-approval for the CT scan, and I was approved. On the day of my appointment, I went in for my scan. I believe I made a $10 copay at the time, but was not told that I would be responsible for paying for any other portion of the scan. Now, several weeks later I've received a bill from the Radiological Clinic for about 60% of the cost of the scan, and my statement from Medica says that I've used up the exact same number of dollars for my out of network deductible. I shouldn't be paying anything for this service- it's supposed to be 100% coverage for in network Lab and Diagnostics. This was at an in-network Radiological clinic, referred to by an in-network ENT, referred to by a in-network family clinic. What do I do? How do I fight this?

Call your insurance company and explain that this provider is in network. They most likely screwed up and processed the claim as non-par. If they say that the provider is non-par (non-participating) then explain to them that you received pre-approval. Although in many cases, an approval can be made without regard to the participating status of the provider if you have an out of network benefit. The fact that the Radiology clinic collected a $10 copay indicates they are contracted.

Are you sure the Radiologist was In Network? Did you personally check the provider directory for your benefit plan? I have seen thousands of cases where a member's PCP or other contracted doctor will refer them to a non-participating specialist or lab or radiologist. Unfortunately, it is your responsibility to ensure the provider is participating. Also, when the provider is part of a clinic, don't assume if one is participating that all of them are participating. Many times, the insurance company will contract with the individual doctor if they can't get an agreement with the whole practice. It sucks, I know.

But, definitely start with your insurance company.

 

[tattoou2]

You have the right to appeal your insurer's decision. Write a letter explaining you are appealing and why.

 

[Clutz]

Thanks for the info ecclesand. No one had explained this to me previously. I went and looked up my doctor (Radiologist) and he does seem to be listed with my health care provider network (HealthEast), so hopefully it's just a mistake. I do appreciate the completeness of your answer though. I had assumed that if the procedure was pre-approved and they collected the $10 copay, everything was good to go. I grew up in Canada, and it's my first time using a private health care provider, so some of the details were a bit unclear before your explanation.

Cheers to you,
Brad

 

[ecclesand]

Quote:

Originally Posted by tattoou2 /img/forum/go_quote.gif You have the right to appeal your insurer's decision. Write a letter explaining you are appealing and why.

Quote:

Originally Posted by Clutz /img/forum/go_quote.gif Thanks for the info ecclesand. No one had explained this to me previously. I went and looked up my doctor (Radiologist) and he does seem to be listed with my health care provider network (HealthEast), so hopefully it's just a mistake. I do appreciate the completeness of your answer though. I had assumed that if the procedure was pre-approved and they collected the $10 copay, everything was good to go. I grew up in Canada, and it's my first time using a private health care provider, so some of the details were a bit unclear before your explanation. Cheers to you, Brad

And that is a good assumption. tattoou2 is correct...if they still deny the claim, you have the right to file an appeal. Also, if they give you any runaround, threaten to file a complaint with the Insurance Commissioner in your state. These health plans (aka insurers) don't like having to explain this sort of thing to the Insurance Commissioner. When you call them, ask them to reprocess the claim.

If the provider is in your directory as contracted in the network you belong to, then this is definitely a screw up on their end...either with processing the claim, or not updating their provider directory.

I've been in this industry for almost 20 years both on the provider side and the insurer side so I know most of the games they play (both providers and insurers).

Good Luck!

 

[BlindTiger]

welcome to our health system.
that's why I'm glad I have Medicaid, sure I don't get to choose who my MD is
but I never get a bill. we all gonna die sometime.

actually you don't get to choose your own MD if you're in an HMO, too.
you get to choose from a list. same with me, but I get fewer choices.

 

[kool bubba ice]

Insurance companies are a joke. Some are dropping cancer patients due to the cost. Where is that in the fine print. Hospitals just care about money. I was rushed to ER. The first thing that came out of the nurses mouth was, can I have your insurance card. She wasn't nice about it. My companies insurance covered the cost, yet the hospital keeps sending me bills. My company had to tell them 3 times that I owe nothing. They are very inefficient in regards to paper work.

 

[Happy Camper]

Hospitals have gotten to be like lawyers. They throw a hand out to as many entities as they can collect from, so no, they aren't wasting their efforts. If communication fails, they could get more money. Billing is done automatically. I had to pay cash in order to have a litho done (no ins.) and still got billed.