LM: healthcare plan rejected care, says the won’t pay

I received a bill from a recent overnight hospital visit.. for about $14,500. My (employer provided) "healthcare plan" then sent me a letter saying the visit was "reviewed and we determined it was medically unnecessary, so berkeley you".

I went to the ER after a 2nd instance of unexplained (significant) bleeding about a week after a colonoscopy - was then evaluated and the ER doctors admitted me for overnight observation + fluids and blood work every four hours.

I damn sure voluntarily showed up at the ER because I was scared and didn't think it was wise to "wish it away". When the doctor says we need to admit you.. I stayed.

My employer has some kind of "service" to help with medical plan issues and I asked them for help but I suspect I'm just wasting days waiting for them. I have not spoken to the hospital yet - I'm sure they'll remind me I agreed to pay whatever my "plan" doesn't.

Final note: My wife has also worked in this hospital for the last 12 years  

WWGRMD?

Politely tell them to pound sand and pay up. Seems the given mo anymore is to deny then "magically" it's ok if you push back on their no payment.

Edit: most initial denials are non medical people reviewing claims.

You had an MD at the hospital say your stay WAS necessary. 

If you have an attorney (or if you can access one through legal aid), get them to draft a letter stating you will be filing a complaint with the Office of Insurance and Safety Fire Commissioner in Atlanta.

Demand they supply documentation - in writing - from their staff MD outlining their specific reason(s) for denial of your claim, ask where their staff MD received their medical training, as well as how long they have been practicing medicine.

Give them a drop-dead date to respond (10 days).

Finally, have the attorney assure them that they will be following each communication to you with interest and that they will proceed with additional actions as required until you believe a satisfactory resolution has been reached.

If this letter is addressed to the Board of Directors of the hospital's parent company, my bet is what you will receive back is an apology for their error.

In reply to CJ :

Re: last paragraph. What error has the hospital made?

Thanks for you response. It pains me to think I would need to involve a lawyer for an ER visit. 

Yeesh. I'm no help, but yeesh.

Would they deny your claim if you had uncontrollable bleeding anywhere else?

Ugh, what a PITA.  For starters, Id look in your MyChart and find the ED provider note.  It will have his/her thought process and clinical discussion about why they decided to admit you for observation. 

My guess is that they actually had an appropriate rationale.

A lot of these issues can be traced to miscoding the bill. I usually work with the hospital to fix. 

In reply to XLR99 (Forum Supporter) :

Hey now. I see what you did there.....

I'd say that it's probably worth talking to the hospital, both to find out if there may be any coding erros and also to let them know what's going on in the hope they're willing to work with you instead of setting debt collectors on you. Right now you've got some leverage because they want your money and it'd look pretty bad if the insurance denied the claim because they messed up.

Plus, there should be an appeals process with your insurance - Internet Rumour (tm) has it that at least one big US health insurer is making a bit of a habit of just denying claims recently with not much in the way of evaluation.

Before rolling out a lawyer, I'd suggest reading up on how their appeals process works and then basically sending them an appropriate letter appealing their decision and asking for the documentation as CJ suggested. Depending on their response, you can always ratchet up the unpleasantness level and get a lawyer at that point. And of course talk to the state regulator for insurance.

Oh, and I'd also let your employer's HR people know. They might not be able to do something right away, but if they're any good they're probably going to have a word with the insurance if there is a pattern. Well, one can hope.

States and the Federal government have offices that deal specifically with issues like this.  Might be worth researching and contacting them, in addition to getting legal advice.  

Make sure all the documentation is in order- I've had issues with bills coming to me as "denied" by insurance because the insurance company was put in wrong, or the name was misspelled, or other stupid crap like that.  They'll look for any reason they can to deny a claim.  There's a lot of fraud out there.  

Lastly, and somewhat unrelated to the insurance issue....this is not the first post-colonoscopy problem I've heard of recently.  They recently moved the age for recommended first colonoscopy down from 50 to 45.  I'm wondering and concerned if the rash of increased procedures is causing problems.  It's concerning to me as I'm in that "45 to 50" age group and have not yet gotten one.  But I have family asking me if I have, and even BookFace is sending me targeted ads to get one.

1. Call company that is denying you and ask why. There may be specific diagnoses or something they need to see before accepting as medically necessary.

2. Call hospital and tell them what company number 1 says. 

3. Let them chew on it for 6 months. 

4. If insurance still won't pay, ask hospital for financial assistance. They should be able to provide plenty of help. Ask about prompt pay discounts and auto-pay discounts and payment plans as well. 

Also, I don't know how large your company is, but you may want to mention this to HR. They are the ones who purchased these insurance plans, and they might find the feedback useful next selection period.

volvoclearinghouse said:

States and the Federal government have offices that deal specifically with issues like this.  Might be worth researching and contacting them, in addition to getting legal advice.  

Make sure all the documentation is in order- I've had issues with bills coming to me as "denied" by insurance because the insurance company was put in wrong, or the name was misspelled, or other stupid crap like that.  They'll look for any reason they can to deny a claim.  There's a lot of fraud out there.  

Lastly, and somewhat unrelated to the insurance issue....this is not the first post-colonoscopy problem I've heard of recently.  They recently moved the age for recommended first colonoscopy down from 50 to 45.  I'm wondering and concerned if the rash of increased procedures is causing problems.  It's concerning to me as I'm in that "45 to 50" age group and have not yet gotten one.  But I have family asking me if I have, and even BookFace is sending me targeted ads to get one.

Apologies for the slight derailing....

my doctor just recommended cologard (cologuard?) as an alternative to a traditional colonoscopy. Said it's as good and just poop in a little tub that you mail in. 
 

super easy and quick results.   
 

I am not a representative nor do I receive any benefits from any of you guys pooping in a little bucket. 

In reply to CJ :

I wouldn't jump straight to a lawyer. The hospital does have patient advocates - I'd contact them first and see what advice they have. They see insurance issues like this all the time, and it's in the hospital's interest to resolve coverage conflicts prior to balance billing the patient, if for no other reason than that the chances of the hospital seeing revenue is higher. 

The insurance company likely isn't reviewing your chart in full here - they are working off of the claim submitted from the hospital. The claim is made up of codes for the procedures (i.e. actions they took while you were there), and diagnosis codes. My guess is that there are diagnoses either not properly coded or missing from the claim, that would have supported the need for an inpatient stay. Depending on the operating procedures at this hospital, it might be that diagnoses aren't coded off of chart notes right away, so the supporting diagnosis might not have made it onto the initial insurance claim. The appropriate next action here is for the hospital to amend their claim and send supporting documentation if necessary - if the hospital proves medical necessity and you still don't get a coverage decision, then it would be time to lawyer up.

I'm really just repeating things other have said, but lots of times this is an encoding error since no insurance agent truly ever reads these except on a randomized quality control basis.

Find out if the hospital has either social work that does billing issues, or their own billing department. Post-procedure complications are absolutely covered (I think even by the Affordable Care Act) but these insurance demons may still fight it.

jfryjfry said:

volvoclearinghouse said:

States and the Federal government have offices that deal specifically with issues like this.  Might be worth researching and contacting them, in addition to getting legal advice.  

Make sure all the documentation is in order- I've had issues with bills coming to me as "denied" by insurance because the insurance company was put in wrong, or the name was misspelled, or other stupid crap like that.  They'll look for any reason they can to deny a claim.  There's a lot of fraud out there.  

Lastly, and somewhat unrelated to the insurance issue....this is not the first post-colonoscopy problem I've heard of recently.  They recently moved the age for recommended first colonoscopy down from 50 to 45.  I'm wondering and concerned if the rash of increased procedures is causing problems.  It's concerning to me as I'm in that "45 to 50" age group and have not yet gotten one.  But I have family asking me if I have, and even BookFace is sending me targeted ads to get one.

Apologies for the slight derailing....

my doctor just recommended cologard (cologuard?) as an alternative to a traditional colonoscopy. Said it's as good and just poop in a little tub that you mail in. 
 

super easy and quick results.   
 

I am not a representative nor do I receive any benefits from any of you guys pooping in a little bucket. 

Continuing the derailing:  When he sent me off to have "things" checked out, my GP told me that since I didn't have any family history the method he recommended was whichever method I would actually do.  When I pressed him further, he said that the poo-stool service method was pretty good but did have a higher false negative rate than the traditional camera method.  The delta is not large enough to worry about for someone relatively young with no personal or family history, but if something was just starting to form there was more of a chance that the camera would catch it.  The other reason I went for the colonoscopy was that if it came back clean, I'd be good for 10 years, but the Cologard would need to be done again sooner.

And as for the insurance thing, a conversation with both the hospital and the insurance company is in order starting with the premise that one shouldn't attribute to malice what could easily be attributed to error.  It's all basically coming down to one computer asking another computer for money and that computer tells it no so the first computer mails you a bill.  I'd bet that nobody's really looking at or thinking about it until the computers get it wrong.

In reply to wae :

Interesting about the Cologuard.  I think I'd rather poop in a bucket annually (which has effectively zero chance of side effects, since I poop every day, the only difference being the receptacle) than have a camera sent the wrong way up a one-way street once a decade.  

Back to the company front, if you have a good HR person, talk to them first.  At the last place I worked, the HR director made it very clear that they wanted to be first contact for any issues like this.  She was pretty fierce about getting things like that resolved.   She was replaced with a typical HR drone and he wasn't nearly as effective, but it's still worth asking.  I had three issues like this that she managed to resolve somehow, but I never found out how :)   I just mentioned "hey, I had this bill rejected, any idea who I should talk to?" And *poof*, it was solved :)

Thanks for all the replies. Update time:

On Thursday (yesterday) I contacted the company my employer hired as a benefit - to help us navigate HC (finding specialists, comparing rates.. help with claims). I laid out my concern and sent them all the paperwork I had received. They had me complete a form giving them the right to see my records (and they're already familiar with our plans - mine is a HDHP, good for people that are generally very healthy which I have been for the most part. And expensive if you need some care). 

This morning I received a notification from the "benefit" guy - laying out a totally different set of numbers. It says the medical plan will in fact pay and it appears to show my 20% "out of pocket" cost at around $1,100. The math seems funny so I'm going to read that a few more times and see what else I get in the mail over the next week or so (Fool me once..).  But I'm a lot more optimistic at the moment. 

Now on to the TMI section of this post.

Regarding colonoscopy I have some family history so I got my first scope at 42. Found a polyp and they excised it and I was told to do it again in five years. At 47 they found another tiny polyp, same thing. So this year at age 52 it was like Groundhog Day. Another tiny polyp, excised. Among all this i developed an annoying 'Rhoid. THAT was the cause of bleeding but it took a night in the hospital to confirm it wasn't the excision. After that last scope (on a Monday) I was fine but that Friday I had a lot of blood. Just walking around and then "WTF!". I was quite concerned but decided to clean it up and ignore it. The following Wednesday something broke open and I bled a berkeleying frightening amount - which prompted my visit to the ER. 

tl;dr

don't sit and use your phone on the toilet....

In reply to OHSCrifle :

Working the job I do, I always tell pts that one drop of blood is a bloodbath in the toilet from an aggravated or aggressive BM.

You typically have to do serial cbc's to determine if it's an internal hemorrhage or not, plus all the other signs to look out for at that time.

In reply to OHSCrifle :

Glad you seem to be on the path to figuring it out.  Like you, we're on a HD plan.  Fortunately they allow one to contribute to an HSA, which rolls over from year to year and has some tax advantages.  Maximum yearly contribution for a family in 2023 is $7050.  IMO it's right up there with a 401k in terms of priorities for saving in.  You can usually invest the money in an HSA similarly to a 401k.  

20% OOP sounds about like ours, they're probably all pretty typical.  There should be a yearly out of pocket max per person/ per family, too.

TMI - Yep, literally, E36 M3 and get off the pot.  We're biologically designed to squat in a field; sitting on a throne isn't natural.  Toiling on the toilet is bad for 'roids.  I've found that prolonged, excessive drinking can make them worse, too- probably because of the dehydration/ constipation effect. 

Coffee, fiber, and plenty of hydration = happy poop pipe.

In reply to OHSCrifle :

The medical industry is a lot like the used car industry. They shuffle numbers around so fast it's mind-numbing. All I can say is don't trust them. At all. 

Ranger50 said:

In reply to OHSCrifle :

Working the job I do, I always tell pts that one drop of blood is a bloodbath in the toilet from an aggravated or aggressive BM.

You typically have to do serial cbc's to determine if it's an internal hemorrhage or not, plus all the other signs to look out for at that time.

Bingo  Serial cbc's (every 4 hours) is why I was admitted.. 

I'm firmly in the camp of id rather have the more thorough scope up the poop chute than the drop in the bucket that makes you get scooped if it's suspect. 

PSA, half the fun of a colonoscopy is charting your weight loss through the prep process... IIRC I lost 11 lbs in just a few hours.

Good to hear they're already down that far. I've found a lot of this insurance overpayment is because people get overwhelmed and they refuse to push back; they know damn well if it goes to court (somehow) the jury rules in favor of the patient nearly 99% of the time, so they intentionally do everything they can to stay away.

Yeah, blood spreads real bad; that's it's job lol. I once had a patient who had slashed open one of their arteries in the trauma bay and had bled maybe a pint of arterial on the floor before we got it tourniqueted and sealed-  it had spread out in an 8 foot semicircle of clotted jelly that was crazy slick. I was shocked I didn't fall on it.

Toyman! said:

In reply to OHSCrifle :

The medical industry is a lot like the used car industry. They shuffle numbers around so fast it's mind-numbing. All I can say is don't trust them. At all. 

berkeley, I'm a nurse and I second this. Insurance companies are the goddamn devil.