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(HIP) Health Insurance Problem

Discussion in 'BBS Hangout' started by JumpMan, Dec 9, 2005.

  1. JumpMan

    JumpMan Contributing Member
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    First off, thanks to anyone who offers advice, this is my situation.

    I first got my Pacificare insurance (from my job) on June 1st, 2005, never had it before as an adult, I'm 23.

    In early August I noticed that I was having trouble hearing in my right ear, so I stink my finger in it and I notice this bump, went to the Doctor and he diagnosed it as a fur uncle and keloid, disgusting I know, after a few weeks of anti-biotic treatments he said I would need "laser" surgery to get rid of it because it wasn't responding to his treatments. He said I would have to pay the insurance premium and whatever percentage my plan requires, so I paid the $1000 premium and the 20% of the left over costs for it, which was another $1000. On September 20th I had my surgery.

    A month or so went by and the insurance company sent me statements that I was NOT responsible to pay for the rest of the charges, everything seems fine, right? Well, now they're re-sending me those EXACT same charges except they now say that I AM responsible to pay for them because they deemed my condition pre-existing. Which is crap, the truth is that I didn't have it before June 1st, and they can't prove that I did anyway because I never visited a Doctor until mid-August.

    I called the Surgery Hospital, the largest of the reversed charges, and they said that the insurance company is trying to pull one on me and that I will have to file an appeal and fight with them until they pay. Apparently, they know that my condition couldn't have been pre-existing because it was an infection, so they're not going to charge me unless they absolutely have to.

    My question to you guys is if any of you had gone through similar situations? What did you do? What should I do? Are they going to break my legs if I don't pay?

    I appreciate any advice, good or bad.

    Thanks!
     
  2. bobrek

    bobrek Politics belong in the D & D

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    Were you covered under a previous insurance plan on May 31, 2005?
     
  3. JumpMan

    JumpMan Contributing Member
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    No. The problem is they think I had my ear problem before June 1st and since I didn't have insurance before they are rejecting the claims, at least that's what they tell me. If the real problem is that I didn't have insurace before June 1st then I guess the case is open and shut, and I have to pay, but then that would mean that if I was in an accident today and needed surgery they wouldn't pay for it because I didn't have insurance before, right? And they're not arguing that, they know I didn't have insurance coverage before, what they are telling me is that the my problem was pre-exisiting before June 1st, therefore they don't have to pay for it.
     
  4. flamingmoe

    flamingmoe Member

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    hehe fur uncle?

    I know you meant furuncle, but I lol at your typo
     
  5. bobrek

    bobrek Politics belong in the D & D

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    You'll have to fight the machine :) . If you had insurance with another company on May 31 then even though it could be a pre-exisiting condition, you had health insurance which negates that (at least that's what I've been told).

    It sounds as if the hospital/doctor are willing to work with you. You ought to have the hospital insurance folks contact your insurance company and see if they can get things straightened out on that level.
     
  6. JumpMan

    JumpMan Contributing Member
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    Yes, that's what it sounds like, they told me that I'll have to be careful with them because they tend to misplace records, misread dates, and misinterpret facts all the time.

    If I have to pay I will pay, but if they're wrong they're wrong, either way they're screwing up Christmas for me.

    And, Thanks!
     
  7. famicom

    famicom Member

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    That does suck, did you ask the hospital how in detail you can handle it? They sound like they are familiar with this or (as the other poster) ask them if they can handle it for you. I'm 23 w/insurance too so I'm still kind of new to this stuff as well but I wouldn't pay that much!
     
  8. Dubious

    Dubious Contributing Member

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    (I'm not a lawyer just had some insurance/surgery problems)

    Wasn't the surgery pre-approved by the surgical center before you had it?
    It should have been which would make it their responsibility to collect from the insurance agency. Has your doctor written a letter to the insurance agency telling them the condition wasn't pre-existing.

    In my case (long story not exactly like yours) I worked with the business manager of the surgical center in a friendly way and when he couldn't collect from the insurance comapany he settled for the Blue Cross rate for the proceedure which wasn't much more than I had already paid out of pocket and 'wrote off' the rest of it.

    By the way this is just the way the medical business works out there these days, Standard Operating Proceedure (pun intended). Insurance companies are for profit businesses and it makes them more money to have their office staff contest every thing they can. The business manager at the center deals with it every day and I would guess will be very willing to help you out.
    Call for an appointment and go talk with him.
     
  9. JumpMan

    JumpMan Contributing Member
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    famicon, be careful, just get the facts straight, unfortunately I didn't. I haven't talked to them in detail yet, but I plan to ASAP.

    I'm thinking yes, all they charged me was 20% of their total charge, so I guess the insurance company approved it before. Yes the doctor apparently sent them my medical records, and they told me that they received them and decided that it was pre-existing. I have no idea how they came to that conclusion since the only FACTS they have to work with are dates, all of them at least 10 or so weeks after June 1st.

    Business manager at the surgery center? I'll check that out.

    Thanks!
     
  10. giddyup

    giddyup Contributing Member

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    It's generally important to keep continuous coverage. If you are between jobs or without a job, get a short-term, interim health policy or a more permanent high-deductible. I use AssurantHealth.com.

    The industry uses the term "credible coverage" and both of those qualify.

    Under these circumstances and considering their own profit motive, it is understandable that some department manager in the claims department might challenge the claim so that his numbers might look better.

    If you can get the medical evidence that it was not pre-existing such that a prudent person would have sought medical care for the symptoms, then you might win out... and you should win out.

    I'm in the insurance business, but I don't work a lot with group insurance, but this is my .02.
     
  11. Fatty FatBastard

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    Pretty simple answer:

    If the insurance you have at work is "Group" insurance, they have to take all conditions, pre-existing or not.

    If you were given an "Individual" policy, they have conditional coverage during your first year and they can decline coverage to what they deem as pre-existing conditions.

    Talk to your HR dept.

    But,as an aside, if you filled out an application asking about your health when you took the coverage, you're on an "Individual" policy.
     
  12. JumpMan

    JumpMan Contributing Member
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    The only medical evidence I have is the date of my first Dr's visit, and his diagnosis, sometime in mid August IIRC, that's when I first noticed it. I'm trying to get a hold of the doctor, but his office is hardly ever open now-a-days, he was a very experienced doctor in Pasadena and I'm afraid that he has probably retired.

    Hmm... That's another thing I was worried about, I don't want my bosses to get into problems with the insurance company, but I'll ask them about that.

    Thanks!
     
  13. bronxfan

    bronxfan Contributing Member

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    i'll give my two cents (i'm a physician and hate crap like this.... insurance companies win by a wearing you down in paperwork)...

    anyways first of all, not all group policies cover pre-existing conditions, so they may be right to decline if they prove it was pre-existing. but the more important thing is how could they feel it was pre-existing. if they feel it was some defect in your ear canal that got infected - then the antibiotics was for the infection but the surgery was for the "defect".

    one likely place for error is if at some point the doctor wrote something like "symptoms x 2months" or "a while", instead of writing "symptoms x 2 days". most docs, write durations of symptoms vague, unless its very important. i'd try and get the office and operative notes and review what your surgeon put in his notes.
     
  14. Fatty FatBastard

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    For a group policy to exclude anything, it would have to have a waiver signed specifically excluding those certain things.

    That's why individual insurance is so much cheaper than group. Group policies have to cover everything.

    And JumpMan: Don't fret about asking. That's what an HR dept. is for. BTW, how many employees do you have at work?
     
  15. JumpMan

    JumpMan Contributing Member
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    First of all, I have to state that the doctor who first diagnosed me and performed my surgery passed away, that's why I couldn't get a hold of him. :( From what I can tell from my visits he was a nice man that served until he couldn't anymore and I'm sure he would be helping me now. Second, thanks for everyone's advice, it really helped, today 5 months have passed since this has been updated, and I need some more advice.

    Their conclusion of my appeal finally came in today, they denied every claim relating to my surgery except for one that I think was less than a hundred dollars.

    Their reason word for word:

    Claims denied as preexisting for DX 701.4 Keloid Scar, DX 380.21 Cholesteatoma External Ear, and DX 709.9 Skin Disorder Nos, respectively.

    Respectively to my primary physician, the hospital where I had my surgergy, and my anesthesiologist.

    ::A paragraph with a complicated definition of a preexisting condition::

    Followed by:

    Pacificare confirmed with medical records that the Enrollee has not been treated by these physicians prior to 09/12/2005. Therfore, services received on 09/12/2005 and 09/20/2005 were outside the preexisting timeframe. Claims will be sent back for reprocessing and paid consistent with the enrolle Schedule of Benefits. Enrolle remains liable for any applicable copays, coinsurance, deductible and/or charges that exceed Maximum Allowable Fee.

    The thing I noticed was that Cholesteatoma External Ear, that's the first time I've ever seen those words. My diagnosis was a fur uncle that keloided, something like that.

    Now, I didn't get that thing that I thought was a pimple in my ear until the beginning of September 2005, I went to the Doc after it popped while I was sleeping and didn't go away a few days later. He told me it was a fur uncle that keloided, he did what he could to remove it for a week, and decided on surgery. My coverage started on June 1st, 2005... Should I surrender and start paying or is there anything else I can do?
     
  16. giddyup

    giddyup Contributing Member

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    Never surrender!

    This: "Pacificare confirmed with medical records that the Enrollee has not been treated by these physicians prior to 09/12/2005. Therfore, services received on 09/12/2005 and 09/20/2005 were outside the preexisting timeframe. Claims will be sent back for reprocessing and paid consistent with the enrolle Schedule of Benefits. Enrolle remains liable for any applicable copays, coinsurance, deductible and/or charges that exceed Maximum Allowable Fee."

    ...isn't this good news? The language admits that you had not seen a physician for this condition prior to you dates of treatment. The claims that are being sent back for reprocessing are the claims that were DENIED aren't they? Then they go on to say that they will be paying consistent with your benefit schedule-- with you liable for deductible, co-pays, coinsurance and excess charges--- ALL NORMAL OUTCOMES.

    Yet all this is within the framework of your saying that their final conclusion is a denial of the claim based on pre-existing condition... :confused:

    If they were going to deny again based on pre-existing condition, wouldn't they just say that straight out? This seems inconsistent.

    Why do they refer to it as a keloid <b>scar</b>? Have you had this problem before? The language of "scar" lends itself to pre-existing interpretations. As FFB pointed out, unless they asked you about it on application and/or you mis-represented to them (even accidentally), this should not be a pre-existing condition on a group policy.

    Is it possible that the doctor's office coded your treatment wrong when they sent PacificCare the bill? That happens-- simple human error. Who has your medical records? What did the dead doctor do with them? Did somebody take over his practice? Find and get them.

    Part of the game is just to confuse and frustrate you until you give up...
     
  17. JumpMan

    JumpMan Contributing Member
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    Sometimes I think they speak in double negatives... This is the rest of the letter:

    Enrolle is disputing claims for services incurred with Dr. Robert Pearl on 09/12/05, Bayshore Surgery Center, Dr. Karla Medina and Dr. Susan Streusand on 09/20/05.

    The claim for Dr Susan Streusand was applied to the enrollee's $3000 Non-Participating Provider Individual Calender Year Deductible after allowing for the Maximum Allowable Fee for Non-Participating Providers.

    The other claims were denied as preexisting for DX 701.4 Keloid Scar, DX 380.21 Cholesteatoma External Ear, and DX 709.9 Skin Disorder Nos, respectively.

    ::A paragraph with a complicated definition of a preexisting condition::


    Followed by:

    Pacificare confirmed with medical records that the Enrollee has not been treated by these physicians prior to 09/12/2005. Therfore, services received on 09/12/2005 and 09/20/2005 were outside the preexisting timeframe. Claims will be sent back for reprocessing and paid consistent with the enrolle Schedule of Benefits. Enrolle remains liable for any applicable copays, coinsurance, deductible and/or charges that exceed Maximum Allowable Fee.

    We will work with the Claims department to ensure that these laims are processed in accordance with your benefit plan. The enrolle will remain responsible for any applicable deductibles/coinsurance as outlined in the Schedule of Benefits are well as any charges that exceed the benefit maximum.


    The way I understand it is that the last two paragraphs are copy and paste type deals that only apply to Dr. Streusand who did the lab work.

    I never had that problem, I don't know much about this stuff, but from what I understand; I got "lump" in my right ear, diagnosed later as a fur uncle (an infection of a hair folicle), it burst and it didn't heal properly creating a keloid (an overgrowth of tissue at the site of a healed injury). The doctor diagnosed it as; The right ear reveals a large furuncle completely obstructing the canal along with a keloid in the canal., the preoperative diagnosis was; Keloid and caruncle (that must be a typo, I think only women get caruncles) completely obstructing the right external auditory canal.

    His office closed and no other doctor took over, his secretary took over and she sent me everything that she sent the insurance company, he didn't use diagnosis codes, just what I wrote above.

    I'm going to make more calls to everyone today... Thanks!
     

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