An Insurance Tale

We have enjoyed this summer so much compared to last year at this time. Dale was in and out of the hospital for a large part of the summer and the rest of the year he was making the long climb back. We recently went to Dallas to have a procedure done and before we left we were presented with a bill that was from last year.

When we got home I called the insurance company to see what happened. Medicare had paid their part but our private insurance was denying the claim. They initially said that it was because the hospital didn’t precertify. Dale of course didn’t call them because he was half dead from infection and hallucinating due to the pain medication (given to him by a hospital I won’t name since they recently showed a desire to frighten anyone who publishes negative opinions about them by suing them).

Next they claimed that the hospital didn’t provide enough information to convince them that the procedures in the list of charges were necessary. I proceeded to explain exactly what the procedures were and why they were done and you can trust me when I say they were not elective. The customer service person I was speaking to said the only thing I could do would be to request the records from the hospital and send them with a letter asking for an appeal to the insurance appeal department. I had already given permission for the hospital to file an appeal on my behalf about 8 months ago. We have requested records from the hospital for ourselves over a month ago and still haven’t received them so this put us in an interesting situation.

I explained to the person on the phone that this was not going to be a workable option and that I needed to speak to someone in the appeals department. She replied that the appeals department doesn’t speak to the people who file claims. You have to communicate with them in writing. I asked to speak to someone who could help me. She told me (in a rather sarcastic tone) that I could speak to someone else in her department and they would tell me the same thing she was telling me. I asked to speak to a supervisor and was put on hold for fifteen minutes (I timed it and the elevator music wasn’t lousy) before someone answered.

This new person checked back and found that the hospital had sent records – 131 pages to be exact. The reason the claim was being denied was because the doctor’s notes were not legible. We now have three completely different reasons why the claim has been denied and I still haven’t been granted an audience with the great and powerful grand pooba of appeals. I have also patiently explained to each person I have spoken to, what was done and why.
I called the office of the admitting doctor and the person who deals with insurance there got out the notes and found she couldn’t read them either. The ball is in their court now.

I wonder if Michael Moore will be doing a sequel – “Sicko II” – I may have a story for him.

3 thoughts on “An Insurance Tale

  1. Frances

    I was at my local doctor yesterday for my annual checkup, and we were trying to decide how she needed to code my visit so that my insurance would pay for it. She said “I’m not very popular around here when I say this, but it’s got to be about time to start talking about socialized health care.”

    After I picked my jaw up from the floor, I said I agreed with her, but that idea has about as much chance of happening as a PISD/NLISD merger…

  2. B.J.

    This is the blog police. We were told by of your comments that violate our policy of not saying bad things about even if they are true. We can’t say who actually is, because they might then sue us.

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