insurance company denial for payment (just a little vent!)

[Guest guest]

Hi All,

Many of us have issues dealing with health insurance denying a service

which should be covered. My daughter had a colonoscopy recently and

the hospital sent her pathology to a lab which the insurance is

refusing to pay for because it is " out of plan " . We had no say in

which lab the hospital used so are disputing the denial of payment.

If this is not resolved we will file a formal complaint with the

State's insurance commissioner. This just gets acid going in my

stomach, as if dealing with the PSC is not enough of a problem.

[Guest guest]

Hi ,

I work for an insurance company and see this ALL the time. I actually work for a smaller, self-insured Plan so we are more "user-friendly" than most companies. In situations like this we have our member's fight with the actual hospitals or physician offices. All hospitals and physician offices call insurance companies to verify benefits prior to procedures. They should have verified ahead of time WHAT labs were cov'd and within your network. I would fight this with the hospital because it is THEIR fault. 85% of the cases brought to our office have been taken care of by the hospitals due to fault on their end. Again, because we are a smaller plan I usually step in and handle this for our member's - I won't give up until they take care of the bill.

Then there have been times when the hospitals/labs won't budge so the member will file an appeal with us. In those cases we always override the payment and pay according to in-network benefits - BUT again, we are a smaller plan and believe in Customer Service and doing what is fair for our members. We actually have humans that answer the phone - more than I can say for the insurance Plan I have (unfortunately it's not through my employer).

Good Luck and keep fighting!!

Husband - Crohns - 98 & PSC - 6/05heathersbestmom wrote:

Hi All,Many of us have issues dealing with health insurance denying a servicewhich should be covered. My daughter had a colonoscopy recently andthe hospital sent her pathology to a lab which the insurance isrefusing to pay for because it is "out of plan". We had no say inwhich lab the hospital used so are disputing the denial of payment. If this is not resolved we will file a formal complaint with theState's insurance commissioner. This just gets acid going in mystomach, as if dealing with the PSC is not enough of a problem.

[Guest guest]

Go go!

Keep us updated! Don’t you love all the small print that we never know

about? Who would think something like the insurance company would want a say

in something like the lab used? That is where tons of our charges have come

from too. That was very early on in the diagnosis process and we figured it

out when we got our first statement. Now I purposefully drive the 30 minutes

to Hershey to have his blood drawn for that reason.

From: [mailto: ] On Behalf Of heathersbestmom

Sent: Thursday, July 21, 2005 4:14

AM

To:

Subject: insurance

company denial for payment (just a little vent!)

Hi All,

Many of us have issues dealing with health

insurance denying a service

which should be covered. My daughter had a

colonoscopy recently and

the hospital sent her pathology to a lab which the

insurance is

refusing to pay for because it is " out of

plan " . We had no say in

which lab the hospital used so are disputing the

denial of payment.

If this is not resolved we will file a formal

complaint with the

State's insurance commissioner. This just

gets acid going in my

stomach, as if dealing with the PSC is not enough

of a problem.

[Guest guest]

this happens to my husband everytime the doctor sends the test

to Prometheius. It is out of plan, but the only place that will do

that particular type of testing. I call the insurance and they review

the claim. Everytime they have went ahead and paid for it. It is

worth calling the insurance and asking that the claim be reviewed.

The worst they can do is deny you.

[Guest guest]

,This happened to us as well. I called the insurance and they also refused the prometheis lab for Bill's imuran test. They still wouldn't pay for it even after I explained that it is only one of two labs that do this test.  I had to pay it.Lee this happens to my husband everytime the doctor sends the test to Prometheius.  It is out of plan, but the only place that will do that particular type of testing.  I call the insurance and they review the claim.  Everytime they have went ahead and paid for it.  It is worth calling the insurance and asking that the claim be reviewed.  The worst they can do is deny you. 

[Guest guest]

Lee Bria wrote:

> This happened to us as well. I called the insurance and they also

> refused the prometheis lab for Bill's imuran test. They still wouldn't

Lee -- Please explain whan an imuran test is???? I've been taking

imuran for 11 years and today my drs. did IG testing on me to figure out

what's happening now with my immune system.

Thanks!

Carolyn B. in SC

[Guest guest]

I don’t

know if this is what you mean, but there is a test they did on Noah to see if

his body could metabolize the Imuran before they put him on it. Since she

upped his dose of Imuran last week she has us doing more tests to see that he

is not reaching a toxic level. I don’t know which test it is, but

she said it was a send out. She did it before the liver biopsy so that

the day of it, if she found PSC she could put him right on it. Here are

the write in tests we have to have done in two weeks…TIBC and

ferritin? I assume the ferritin is iron related. I will look to see

if I can find anything about the TIBC. Sorry I am not more help.

From: [mailto: ] On Behalf Of verviers@...

Sent: Thursday, July 21, 2005 8:39

PM

To:

Subject: Re: Re:

insurance company denial for payment (just a little vent!)

Lee Bria wrote:

> This happened to us as well. I called the

insurance and they also

> refused the prometheis lab for Bill's imuran

test. They still wouldn't

Lee -- Please explain whan an imuran test

is???? I've been taking

imuran for 11 years and today my drs. did IG

testing on me to figure out

what's happening now with my immune system.

Thanks!

Carolyn B. in SC

[Guest guest]

Okay, that was

quick. Total

Iron Building

Capacity= TIBC

Maybe it is

just the usual stuff they watch now. His sheet just has the usual CBC,

ESR, INR, PT, PTT, AST, ALT, GGT, Alk Phos, Total bilirubin, direct bilirubin,

total protein, albumin, C Reactive protein, Iron, TIBC and ferritin.

I know when we

had the other test done, they had a separate form for the lab. So maybe

now that he has had that there is a way to do it through the normal stuff they

would do anyway. I know his GGT is staying high so it would not be that

or she would not increase it anymore like she just did.

Sorry I am not

more help.

From: [mailto: ] On Behalf Of verviers@...

Sent: Thursday, July 21, 2005 8:39

PM

To:

Subject: Re: Re:

insurance company denial for payment (just a little vent!)

Lee Bria wrote:

> This happened to us as well. I called the

insurance and they also

> refused the prometheis lab for Bill's imuran

test. They still wouldn't

Lee -- Please explain whan an imuran test

is???? I've been taking

imuran for 11 years and today my drs. did IG

testing on me to figure out

what's happening now with my immune system.

Thanks!

Carolyn B. in SC

[Guest guest]

Dear Carolyn,

If my husband was home I would ask him about this but all I know is

that when Bill went on the imuran they told him that he would need

occasional blood test to check the levels as it builds up and they

might need to adjust the dose. Since he had his colon removed he is

no longer on the imuran for the colitis. He only had his blood

checked the one time. I wish I could be more helpful. If someone else

doesn't have the answer for you I will check with my husband when he

returns from CA.

Lee

> Lee Bria wrote:

>

> Lee -- Please explain whan an imuran test is???? I've been taking

> imuran for 11 years and today my drs. did IG testing on me to

> figure out

> what's happening now with my immune system.

>

> Thanks!

>

> Carolyn B. in SC

>

>