Actual phone conversation with health insurance person (regarding a denied claim)...
Me: The provider called [the company] for a pre-authorization for this procedure. The message received stated that ‘no pre-authorization was required for out-patient surgery, MRI, or CT unless living in [some other county, some other state]'. Which I do not.
Insurance company person: Yes, but that’s the just recorded message. Then they have to call to find out what the benefit requires for the MRI.
Me: But…the message just told them…that no pre-authorization…for an MRI…is needed? And they need to know…that another follow-up call is required??
ICP: Mmm-Hmmm. (very matter of factly) (like she did not hear the crazy of her words).
Me: That makes no sense!
ICP: We need to have…(and she just goes on….never pausing…)
My point is (and I have a few), is that I cannot be the first in my provider’s office with this insurance needing this procedure. It is a capable office staff that has met every need before, and surely would know that an additional, follow-up call was required.
What the ICP said was almost exactly what I wrote above. Maybe not exactly word for word, but almost. There is a recorded message that says no pre-authorization is required. Except that really? One is needed, and a second phone would have told us that. Except that the first phone call? No clue that a second is required.
And when I repeated that? No acknowledgement that the practice is crazy making.
>The procedure was performed in April.
>The insurance company first held off on paying, asking for more information.
>The claim was then denied, because of no pre-authorization.
> Receiving the letter on Thursday, and not being able to talk to the provider on Friday, I spent a weekend wondering, ‘WTH? Was I going to be paying a $4000 bill?’
> I have had to call the insurance company twice and the provider three times…at work…which means finding a place not in cube land where I can repeat and re-repeat the whole story.
> I will probably be receiving bills from those who provided the actual services, and will have to call them and tell them the services have been resubmitted to said insurance balkers, and please don’t turn me into the collections service.
>The insurance company has had my premiums in the mean time. And the providers have not been paid for 4 months, and probably won’t be paid for at least another, maybe two. Nice scam if they can hold onto a few other’s money in a likewise fashion.
What makes me almost want to throw in the towel is how the hard the answers are to come by. How do I know what is covered, what is required, what is needed to make sure all my ducks are in a row?
The benefit book has some pretty good bullet points, but is not totally comprehensive. The website says to call customer service to make sure. Depending on who I talk to, different people hear what I need differently, and answers vary based on their knowledge.
And I have…a few decades…or more….of life experience to base my questions on. Somebody help me if I was 28 and trying to navigate this system.