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  1. #1
    kemper234 is offline Junior Member
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    Insurance Company Refuses To Pay Hospital Bill

    What is the name of your state? SC

    In Jan. of this year my doctor ordered a CT Scan done on my face at my local hospital. The hospital sent me a bill for this procedure...$2147.00...and then my insurance company...United Healthcare...sent me a letter stating that they were not going to pay anything on this bill due to it not being pre-certified by them.

    I contacted my doctor's office about this and they told me that it was up to me to get this procedure pre-certified. I informed them that I have never had to pre-certify a procedure myself and also informed them that no one from the doctor's office had told me to do this. The lady I was talking to changed her tune with me after this and told me that she sees that I have United Healthcare and this is the one insurance company that they have to call and get procedures pre-certified. I then asked her what I was supposed to do.

    To make a long story short...I was told to contact the hospital to see if they would see what they could do to get United Healthcare to pay on this bill. My doctor's office also wrote up a letter for me and got me my medical records and told me to send this in.

    Today I get a letter from United Healthcare telling me that they are still not going to pay on this bill due to my doctor's office not getting me pre-certified.

    Should I sue my doctor for this bill? Please someone help me here.What is the name of your state?
  2. #2
    cbg
    cbg is offline Senior Member
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    It was not your doctor's responsibility to either pre-certify the procedure, or to tell you to do it. It was YOUR responsibility to know what your insurance required and to follow through with it.

    It is your responsibility to pay the bill and you have nothing to sue anyone for.
  3. #3
    ecmst12 is offline Senior Member
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    You have to know your policy requirements and rules. You can't just assume everything will be covered just because you have a policy. It was your responsibility to call your insurance company to find out the requirements, and then inform your doctors office that they needed to pre certify the test. Your doctor COULD have taken the initiative to call without being asked, but they were not required to call unless you had told them it was necessary.
  4. #4
    kemper234 is offline Junior Member
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    Cool Re:Insurance Company Refuses To Pay Hospital Bill

    Maybe I did not state this in my previous post but...not only does my insurance company say that my doctor was supposed to have the procedure pre-certified but...the lady I have spoken to in charge of insurance billing in my doctor's office has told me that I have the one insurance company that requires them (the doctor's office) to call and have certain procedures pre-certified.

    How am I at fault when both the insurance company and my doctor's office state that it was the doctor's office's responsibility to have the CT Scan pre-certified????
  5. #5
    Zigner is offline Senior Member
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    Quote Originally Posted by kemper234 View Post
    How am I at fault when both the insurance company and my doctor's office state that it was the doctor's office's responsibility to have the CT Scan pre-certified????
    Because, the ULTIMATE responsibility is yours.
  6. #6
    cbg
    cbg is offline Senior Member
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    EVEN IF the policy calls for the doctor to do the re-certification, it is still YOUR responsibility to say, "Dr. Smith, my insurance needs you to pre-certify". It is NOT the responsibility of the doctor to say, "Kemper, under your insurance I have to do a pre-certification".

    I used to work for UHC. Don't try to tell me that you have no responsibility.
  7. #7
    k needs help is offline Junior Member
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    authorization

    Your doctors office shows poor patient care. I am a billing manager in a medical paractice in PA. If the faciliy where you had the procdure is a par provider it was their responsibilty to make sure they had authorization prior to the procdure! If they are a par provider and did it without the auth they can not bill you! If they are a non par provder with UHC then they can bill you due to no contract.
  8. #8
    cbg
    cbg is offline Senior Member
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    K, the fact remains that it was the responsibility OF THE INSURED to TELL the doctor to get the pre-cert. It is NOT the responsibility of the doctor to know the insurance requirements of all his patients and tell THEM what their insurance requires; quite the opposite.

    I say again, each insurance carrier (and I specifically include UHC in this) has literally hundreds of policies, not all of which have the same rules. Simply knowing that the carrier is UHC does not automatically mean that (a) a pre-cert is needed or (b) the doctor has to get it. There is no POSSIBLE way the doctor can know the insurance requirements of each and every one of his patients.

    It is the responsibility of the PATIENT to notify the doctor what his insurance requires. Having done that, THEN if the doctor fails to get the pre-cert, the doctor is at fault. But if the patient did not notify the doctor that the pre-cert was needed, then even if the doctor is responsible for making the call to get it, the doctor is not responsible for the failure.
  9. #9
    k needs help is offline Junior Member
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    cbg, I agree with you! There is no way to know all plans of all insurances! I was just making a point that it is like a HMO, if you are a speciliast and you see a patient with out a referral or a waiver signed you can not bill them per your contract with them and the EOB will denie stating providers responsibility, non billable. If the hospital needed a auth or precert to do the procdue and did not have one and is contracted with the insuracne they should not be able to bill the pt.
  10. #10
    cbg
    cbg is offline Senior Member
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    Okay. One more time. Please pay attention this time.

    1.) Not all plans are alike. Therefore, not all plans, NOT EVEN ALL UHC PLANS, have the same requirements.

    2.) It is the responsibility of the patient, NOT THE DOCTOR, to know what the plan says.

    3.) In this instance, the patient did not tell the doctor that it was necessary for him to call for pre-certification

    4.) Therefore, the doctor did not know that he had to call for pre-certification

    5.) Since it was the responsibility of the patient, not the doctor, to know that the doctor had to call for pre-certification, the failure to call was that of the patient, not the doctor.

    6.) The patient, not the doctor, screwed up.

    7.) Therefore, EVEN IF the doctor is a participating provider, he is still owed his money.

    As I said, I worked for UHC. I know what their plans say. If the doctor was supposed to call for pre-cert and he didn't do so because the patient told him to and he forgot, fine, the doctor screwed up and he's stuck. But in this case, he didn't call because the patient never told him to. It was not the doctor's fault. The doctor still gets paid.

    We get it. You're a billing manager. You are clearly NOT an expert on insurance plans.
  11. #11
    ecmst12 is offline Senior Member
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    It does not work that way for hospitals. And in most plans, if the PATIENT does not secure the referral before seeing the specialist, then the patient will be responsible for the cost of the visit.
  12. #12
    k needs help is offline Junior Member
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    cbg, O.K. you worked for UHC, somthing I would not brag about! You are so clever!! To avoid conflicting opinions on this subject from all the so called experts, go to your HR person ask them for the provision in the policy that states that you needed to obtain pre-cert and how they are contracted if the hospital did not verify that the procedure was pre-certed prior to doing it. Since there are so many different policies. If you feel you still should not be responsible for the bill call your insurance commishiner in your state or your state represenative. I guess I just work in a reputable area (Harriburg, PA) and when a patient is referred to have a diagnostic procdure done the facility normally calls for benefits to see if pre-cert is needed to ensure payment!

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