TO: Heidi and all using health care benefits!

[Guest guest]

Health care benefits have been and still are a pet peeve of mine.

After, at one point, spending almost a year trying to get charges

and reimbursements correct, I succeeded in having my insurance

company reimbursed for almost $200,000!

You are right Heidi in questioning charges especially with

the " ceiling " on charges. Most companies including my own have a

$100,000,000 cap on medical charges. After that you are out of

luck. That one million sounds like a lot of money, but believe me

it is " pittance " compared with what the hospitals charge not to

mention the inaccurate charges that are sent to insurance companies.

Usually when your insurance company pays a bill, you get a copy of

the EOB or Explanation of Benefits in the mail. That is what you

have to be very careful in watching. Also, as Heidi has talked

about, get ITEMIZED BILLS for your stays and compare.

I will give you an example of an incorrect billing that resulted in

almost $40,000 of overcharges that I successfully got reimbursed to

the insurance company.

As most of you know, I have injectable pain medication. At the time

when this was first started, I was on TPN, had a central line, all

the supplies that go with that central line as well as nursing

care. As time went on, the central line was lost due to infection

(one of 18 lines to be exact.) Finally, I was in a position to have

to do IM injections (intramuscular). Because my husband had been

taught by home health to do this, he in turn taught me. We had no

nursing care at that point, we just filled the prescriptions.

When the bills were sent to the insurance company by the Infusion

company they were billing for the nursing care also. I would not

have known this had I not looked at the explanation of benefits and

wondered why less than $300 of medicine per month was being billed

and reimbursed by my insurance company at a rate of almost $6000 a

month...........thats right six-thousand-dollars! I started doing

an investigation and found out the infusion company supplying hte

medicine had " put the wrong code " in the computer and indeed was

charging for their nursing services! This infusion company was in

Chicago and I reside in Asheville, NC. Long way for a nurse to have

to come wouldn't you say? Well, I had no problem getting the

problem taken care of and straightened out but getting that money

reimbursed was a nightmare! What I did find out though, it was not

the company that made the mistake causing hte nightmare it was the

insurance company to whom the money was owed! The insurance company

told me that until they had proper documentation they could not take

my word for it. I understood that. But, after they had been

notified by the company who made the mistake, of the mistake and the

fact that they were owed almost $40,000 they left it at that. The

company reimbursed part of the money but not the total (or so I was

told). The insurance company was rude with me and said that if they

didn't get the money back, there was nothing they could or would do

about it that was just the way it was.

At that point, I was furious and told this person that I was sure

the company my husband worked for would be so interested in how they

threw the company money around and I hung up. It wasn't long until

I got a call back from a supervisor who was very cooperative and

informed me that the person I had spoken to was in the office that

very minute with the department head. It did not take long to get

this worked out and find out that indeed the company had been

reimbursed for whole total, not just part of it and they sent me

documented proof. Also, the person who told me that they couldn't

do anything if the company did not want to reimburse money they knew

they had coming, wound up losing her job!

Remember, when the insurance companies and hospital mess with money,

it is YOUR money and once those hospital benefits run out the

insurance company is not going to care what happens to you!

I did not mean for this post to be so long, but Heidi you are so

correct in worrying about that " cap " on insurance reimbursement. It

can and does run out! Also, the insurance company has a running

total in the computer that you may ask about at any time. At one

time mine was over $750,000 dollars but I have had it reimbursed

back down to less than $250,000 dollars now. That is half-a-million

bucks they screwed with!

Kaye