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Insurance claim denied (twice): what next?

post #1 of 16
Thread Starter 
I guess this is an okay place to ask about this ...


A year ago I had surgery on my big toe ... there have been some threads on hallux rigidus and cheilectomies and whatnot in here, and I documented my own experience.

Basically, I went in for one procedure (osteotomy/cheilectomy) and came out with another (arthroplasty). The doctor was to relieve arthritis with the cleanout, but when he opened up my foot, found no cartilage left so he decided to replace the joint.

But apparently he had preapproval for only the intended operation, not the resulting operation, which my insurance company (Cigna) deems experimental and thus not covered.

The doctor's office has handled the appeals (the second was just rejected) ... and now I'm wondering what happens next. I'm doing my internet research, of course, and trying to find all the papers I signed before the surgery, but I was curious if anyone else has had a situation like this, and how they handled it?

eta: The doctor mentioned in passing something about the possibility of a joint replacement, but neither of us really thought the condition was going to be that bad, and so I didn't seriously consider that it would be done. AND, both my aunt -- on my mother's side -- and father (I hit the genetic bad toe lottery) had their same joints replaced within the year before I did, so I had no idea that it would be considered an experimental procedure anyway ... in my family, apparently it's par for the course!
post #2 of 16
You should read your insurance plan and continue to appeal. You will need to follow their procedures and timelines with respect to appeals of denials otherwise, you will be out of luck.

I am an attorney in Denver. If you have questions, please pm m. I am happy to help.
post #3 of 16
Quote:
Originally Posted by skier31 View Post
You should read your insurance plan and continue to appeal. You will need to follow their procedures and timelines with respect to appeals of denials otherwise, you will be out of luck.

I am an attorney in Denver. If you have questions, please pm m. I am happy to help.
+2 (but not in Denver).

Also

-- get a copy of the plan, the summary plan description, and any and all other documentation stating or summarizing your rights as an insured, and read everything.

-- submit all appeals ahead of deadlines, via cert mail return receipt requested.

-- ask your doc's office for copies or printouts of all correspondence (paper or electronic) with insurance company to date

-- write down the name and title of every person you speak with at the insurance company. keep a detailed log of all conversations with insurance co reps.

-- in addition to whatever arguments you may have under the plan itself, ask your doc whether doing the (not preauthorized "experimental" procedure) avoided covered expenses you otherwise would have incurred by not proceeding with the "experimental" joint replacement and instead waiting and undergoing additional or different treatment or surgery. if he can quantify that and you can demonstrate there was "business sense" behind the treatment you received, use that argument

-- read, and follow, the much more extensive advice in "Making Them Pay: How to Get the Most from Health Insurance and Managed Care," by an attorney in DC who specializes in this sort of thing: http://www.amazon.com/Making-Them-Pa.../dp/0312267606
post #4 of 16
It's pretty hard to get anywhere with insurance companies. Your doctor may be appealing that decision, but in the end he will bill you and you will either have to pay it or face a judgment for the full amount. If it's more money than you can afford, talk to a lawyer. If it were me, I would point out to the doctor that I didn't consent to an experimental procedure, and let him know I didn't expect to be billed for it. Otherwise he will just turn the bill over to a collection agent, and you could eventually be looking at a judgment for the full amount.
It sucks for the doctor, and it is no way to provide good health care, but that's the system we have, and you need to protect yourself.

BK
post #5 of 16
And of course the important question...

feeling better?

Going with the idea by TS01, certain costs were authorized and incurred as part of the originally authorized surgery; preparation, anesthesia, hospital or out patient surgical fees, sutures, medications, what-not. The different procedure and artificial joint surely added costs, but I don't see why you should be stuck with the whole thing. On the hand, its insurance policy and nothing necessarily makes sense. :
post #6 of 16
I agree that you need to review all the docs paperwork and see if you ever approved the joint replacement procedure. The doc is probably coverd by some catch-all phrase in his release forms but its certainly worth checking.
The advice about following the exact procedures and time lines outlined by the policy is important.
post #7 of 16
Thread Starter 
Quote:
Originally Posted by Cirquerider View Post
And of course the important question...

feeling better?

Going with the idea by TS01, certain costs were authorized and incurred as part of the originally authorized surgery; preparation, anesthesia, hospital or out patient surgical fees, sutures, medications, what-not. The different procedure and artificial joint surely added costs, but I don't see why you should be stuck with the whole thing. On the hand, its insurance policy and nothing necessarily makes sense. :
Yeah, that's one thing I'm curious about. For all I know, the procedure that was done costs less than the one for which I was approved.

Anyway, thanks to all for the advice. I've been dealing with a CC identity theft issue all summer; boy am I ever stoked to start in with this!!!
post #8 of 16
Also just to let them know not to f*ck with you - consider lodging a complaint with your state insurance department regarding bad faith claims handling. 99 out of 100 of those go nowhere in the department, and even that is a good estimate. but the squeaky wheel gets the grease so you may as well squeak. the colorado insurance department makes it real easy: http://www.dora.state.co.us/Insuranc...erMainPage.htm

i'm not suggesting it's a first resort, but if (when) they say or do something outrageous -- conflicting positions, delay, failure to substantiate their assertion the procedure is experimental, inconsistency with other insurance companies which cover the position, you name it, fire away.

haven't read it but the CO ins dept has a publication you may already have seen, and if not should probably read: "What Happens When Your Health Insurance Company Says No Your Rights Regarding Insurance Pre-Authorization and Grievance Procedures" -- http://www.dora.state.co.us/Insuranc...o%20(2-07).pdf

Last - I know nothing about the law firm that published this summary of CO bad faith law but a quick scan suggests the summary would be a useful read for you. The language of the Colorado Unfair Claim Practice Act is set out in full there, along with summaries of CO bad faith cases. Using the statutory language in drafting letters to the insurance company requesting review and reconsideration may get some attention.
post #9 of 16
Years ago when we had a procedure that turned out to not to be covered, we discovered that the agreement the doctors signed with the insurance company had an interesting clause -- they were not allowed to bill the customer for non-covered work that that they did. (I suppose there was some other clause for patients that knew and wanted something done anyway.)

The way it worked out, was the lab just ate the whole bill and never charged us at all. Our doctor did bill us -- we considered objecting, but it was a lot less than the lab work, and we liked the doctor, so we went ahead and paid that part.

I don't know how common such clauses are, but it wouldn't hurt to check.
post #10 of 16
It probably also would be a good idea to try to determine how many similar cases (non-preapproved procedures) your surgeon has been involved in.
post #11 of 16
Welcome to the world of medical insurance. As a surgeon, I deal with this all of the time. Just because your insurance company authorizes does not mean they will pay for it. They even say "authorization is not guarantee of payment". Your situation is worse in that they found something different/worse than expected so you can not expect to have pre-authorized for all contingencies. For those who think it is the surgeon's fault and should not be paid think of it this way...if he had told you ahead of time that one procedure could be authorized but the arthroplasty could not what would you have wanted him to do? Stop surgery and leave you the way you were?

Keep appealing and writing letters and use some of the legal advice above for dealing with insurance companies. They will eventually give in but they want you to give up.
post #12 of 16
Pwdrhnd - it is not so much that I think the surgeon should eat the cost, but that he should have strong motivation (read financial) to support the patient in her struggles with the insurance company.

Of course, my situation was a little difference because it was back when ins. co.'s were pushing "primary care physicians" acting as gatekeepers. In that situation, where they took on that role, yes I think it should be the doctor that takes that loss.

That business model is pretty much gone now, though - now they put the screws to the patient and expect the pain to radiate upward. Think about that for a minute -- the primary cost control mechanism these days is for the insurance companies to make your patients angry at you.
post #13 of 16
Quote:
Originally Posted by Baja View Post


Now when people ask why I don't accept assignment, I can show them this.
.....
post #14 of 16
I'm confused.

Your doctor performed surgery for which he didn't have approved payment for, and which he hadn't informed you in detail (cost, payment, etc.) that he might do.

His inability to get paid is your problem?
post #15 of 16
Quote:
Originally Posted by Garrett View Post
I'm confused.

Your doctor performed surgery for which he didn't have approved payment for, and which he hadn't informed you in detail (cost, payment, etc.) that he might do.

His inability to get paid is your problem?
yep.
post #16 of 16

what did your xray show?

"no cartilage left" is usually not a surprise
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