10k bill health bill insurance company won't pay, need advice

[michaerlscai]

so my dad had brain anuerysm and went through one of those minimally invasive surgery where the doctor put in coils to fill the anuerysm and a stent in the artery.

The insurance company sent him a letter and said one of the things doctor did, called angioplasty (which is something like strech out the artery a little bit (because it was narrow) is not covered because it's 'experimental', that's a cost of $9900.

In one of the email prior to the surgery, the doctor said he won't be doing angioplasty, because streching the artery may adversely affect the anuerysm.

We haven't got the final bill from the doctor yet, my dad is stressed out, he is retired and on a very limited budget. He is also worried because the angioplasty is used, doctor had to use a different kind of stent that's stronger and able to strech out the artery (different stent as discussed with the doctor before the surgery). This might adversely affect the healing of anuerysm.

Sent a email to the doctor ask him to appeal insurance company's decision, haven't got a reply yet.

Anyway, it's something my dad wasn't aware of, didn't approve, the treatment deviated from prior agreement (doctor probably had good reason) the insurance company won't pay, and he is in no way to be able to afford a $10k bill.

who should he go after, the doctor or the insurance company, to get this resolved?

any suggestions, advice?

Also, how can I legally represent my dad on his bahave in this matter, he is 70 year old and it will be too much stress for him to handle this matter.

 

[Ladyback1]

so my dad had brain anuerysm and went through one of those minimally invasive surgery where the doctor put in coils to fill the anuerysm and a stent in the artery.

The insurance company sent him a letter and said one of the things doctor did, called angioplasty (which is something like strech out the artery a little bit (because it was narrow) is not covered because it's 'experimental', that's a cost of $9900.

In one of the email prior to the surgery, the doctor said he won't be doing angioplasty, because streching the artery may adversely affect the anuerysm.

We haven't got the final bill from the doctor yet, my dad is stressed out, he is retired and on a very limited budget. He is also worried because the angioplasty is used, doctor had to use a different kind of stent that's stronger and able to strech out the artery (different stent as discussed with the doctor before the surgery). This might adversely affect the healing of anuerysm.

Sent a email to the doctor ask him to appeal insurance company's decision, haven't got a reply yet.

Anyway, it's something my dad wasn't aware of, didn't approve, the treatment deviated from prior agreement (doctor probably had good reason) the insurance company won't pay, and he is in no way to be able to afford a $10k bill.

who should he go after, the doctor or the insurance company, to get this resolved?

any suggestions, advice?

Also, how can I legally represent my dad on his bahave in this matter, he is 70 year old and it will be too much stress for him to handle this matter.

You need to have a POA (power of attorney) in order to represent your dad in matters like this. Probably need to look into a Durable Power of Attorney.

 

[Proserpina]

so my dad had brain anuerysm and went through one of those minimally invasive surgery where the doctor put in coils to fill the anuerysm and a stent in the artery.

The insurance company sent him a letter and said one of the things doctor did, called angioplasty (which is something like strech out the artery a little bit (because it was narrow) is not covered because it's 'experimental', that's a cost of $9900.

In one of the email prior to the surgery, the doctor said he won't be doing angioplasty, because streching the artery may adversely affect the anuerysm.

We haven't got the final bill from the doctor yet, my dad is stressed out, he is retired and on a very limited budget. He is also worried because the angioplasty is used, doctor had to use a different kind of stent that's stronger and able to strech out the artery (different stent as discussed with the doctor before the surgery). This might adversely affect the healing of anuerysm.

Sent a email to the doctor ask him to appeal insurance company's decision, haven't got a reply yet.

Anyway, it's something my dad wasn't aware of, didn't approve, the treatment deviated from prior agreement (doctor probably had good reason) the insurance company won't pay, and he is in no way to be able to afford a $10k bill.

who should he go after, the doctor or the insurance company, to get this resolved?

any suggestions, advice?

Also, how can I legally represent my dad on his bahave in this matter, he is 70 year old and it will be too much stress for him to handle this matter.

Angioplasty isn't usually the first line of treatment - if they're doing an angioplasty, they're basically dealing with a severe vasospasm (that's basically a severe and sudden narrowing of the vessel), and it may have been the only realistic chance of saving the patient's life.

Because the doctor really doesn't have the time to worry about what may or may not be covered by the patient's insurance, at this point I think all your father can do is try to negotiate the price. In some areas it can be as much as $40k for the procedure.

 

[michaerlscai]

Angioplasty isn't usually the first line of treatment - if they're doing an angioplasty, they're basically dealing with a severe vasospasm (that's basically a severe and sudden narrowing of the vessel), and it may have been the only realistic chance of saving the patient's life.

Because the doctor really doesn't have the time to worry about what may or may not be covered by the patient's insurance, at this point I think all your father can do is try to negotiate the price. In some areas it can be as much as $40k for the procedure.

It's likely the doctor had good reason to do a angioplasty, the thing is he said before the surgery that he won't be doing a angioplasty. my dad had a a verbetal artery it's moderately narrowed. The doctor has seen an angiogram of it prior to the surgery. and he said he will not do angioplasty, and will use a very soft stent that conforms to the wall of the artery.

But the end result is he did a bit angioplasty and used a different stent as discussed, something harder that stretches the arteray.

So he didn't follow the agreed upon treatment plan, and the insurance company is probably finding ways to not cover everything.. yes the total surgery is 40k or something, pretty expensive.

my question is, how can he be responsible for something he is not aware of, didn't agree to at the first place - I agree the doctor probably don't have time to worry about what's covered or not covered.

but this whole thing doesn't seem right in so many levels

1) patient need to be told the treatment plan ahead of time the treatment
2) insurance company shouldn't find ways to reject part of a claim, on something doctor obviously find necessary to do.

My dad need to go back in 6 months to follow up angiogram, so obviously he doesn't want to have a bad relationship with the doctor at this point..

 

[Proserpina]

It's likely the doctor had good reason to do a angioplasty, the thing is he said before the surgery that he won't be doing a angioplasty. my dad had a a verbetal artery it's moderately narrowed. The doctor has seen an angiogram of it prior to the surgery. and he said he will not do angioplasty, and will use a very soft stent that conforms to the wall of the artery.

But the end result is he did a bit angioplasty and used a different stent as discussed, something harder that stretches the arteray.

Yes, I understand that. But sometimes once the surgeon is "in", it becomes obvious that what was intended isn't going to do it. Y'know?

So he didn't follow the agreed upon treatment plan, and the insurance company is probably finding ways to not cover everything.. yes the total surgery is 40k or something, pretty expensive.

my question is, how can he be responsible for something he is not aware of, didn't agree to at the first place - I agree the doctor probably don't have time to worry about what's covered or not covered.

Because that's what he agreed to with the informed consent. A plan is fine, but sometimes once you're "in there", it's not feasible.

but this whole thing doesn't seem right in so many levels

1) patient need to be told the treatment plan ahead of time the treatment
2) insurance company shouldn't find ways to reject part of a claim, on something doctor obviously find necessary to do.

1. Right - it was a plan. Plans sometimes need to change.
2. They're doing what they're legally allowed to do.

It's not like they deliberately misled him...y'know?

My dad need to go back in 6 months to follow up angiogram, so obviously he doesn't want to have a bad relationship with the doctor at this point..

Has Dad tried working with the financial department? Would he qualify for elder services?

 

[cbg]

Pro knows far more about medical treatment than I do, but she comes to me when she has a question about her health insurance.

Your dad (or you if you have his POA) is the one who has to appeal through the insurance, not the doctor. The first thing you need to do is get hold of a copy of the policy. If this is an individual policy, you most likely have one, or would get one from the company. If this is employer sponsored insurance, you would contact the Benefits office of his employer and ask for a copy of the Summary Plan Description (also known as the SPD). They are required by law to provide it on request (though they are not required to drop everything and do it in the first ten minutes.) It may well be on the company intranet. When you have it, look for the section on Exclusions. If you find an angioplasty listed as excluded, then you're wasting your time to do anything other than try to work out something with the financial office - the insurance carrier has NO legal liability to pay for something that's excluded under the policy, no matter what.

If it's not listed as excluded, then elsewhere in the policy will be the procedure for appeals. You need to follow it TO THE LETTER and make sure you get everything that's required in within the timeframes requires. If you're even one day late, the insurance company is within their rights to say, too bad so sad.

Keep in mind that even if you do everything perfectly, an appeal is not guaranteed to work. If you get denied on appeal, come back and I'll walk you through the next step.

 

[Proserpina]

Pro knows far more about medical treatment than I do, but she comes to me when she has a question about her health insurance.

Your dad (or you if you have his POA) is the one who has to appeal through the insurance, not the doctor. The first thing you need to do is get hold of a copy of the policy. If this is an individual policy, you most likely have one, or would get one from the company. If this is employer sponsored insurance, you would contact the Benefits office of his employer and ask for a copy of the Summary Plan Description (also known as the SPD). They are required by law to provide it on request (though they are not required to drop everything and do it in the first ten minutes.) It may well be on the company intranet. When you have it, look for the section on Exclusions. If you find an angioplasty listed as excluded, then you're wasting your time to do anything other than try to work out something with the financial office - the insurance carrier has NO legal liability to pay for something that's excluded under the policy, no matter what.

If it's not listed as excluded, then elsewhere in the policy will be the procedure for appeals. You need to follow it TO THE LETTER and make sure you get everything that's required in within the timeframes requires. If you're even one day late, the insurance company is within their rights to say, too bad so sad.

Keep in mind that even if you do everything perfectly, an appeal is not guaranteed to work. If you get denied on appeal, come back and I'll walk you through the next step.

You make it understandable even for me

 

[michaerlscai]

in the letter from the insurance company they specifically listed angioplasty as not covered for his procedure, based on a policy item they quoted, so Im not optimistic for an appeal.


whats the next step if appeal is rejected?

come on, tell me the next step..

 

[cbg]

I'm not talking about what it said in the denial letter from the insurance company. I'm talking about the policy itself. It does make a difference.

A procedure can be excluded outright, as in "we will never cover this procedure for anyone no matter what the circumstances". It can also be excluded conditionally, as in "Depending on the medical history, prognosis and treatment plan, we may or may not cover this procedure".

Before we can even think about the next step, we need to know which of the two exclusions is being utilized, and for that you need the SPD.

 

[commentator]

First of all, your dad doesn't need to work himself into a tizzy about getting this paid. He needs to concentrate on getting better, and being thankful that his surgery was successful. As you said, it was totally out of his control, he has done nothing wrong, and it will eventually all work itself out. He's lucky to have you to help him and be willing to deal with this.

As someone who has had one heck of a lot of surgeries and procedures, and had several disagreements with insurance companies, and had appeals, I can tell you that cbg is right on the on the money. (I received a string of denial letters from insurance on the tests that showed my heart issues, to the tune of thousands of dollars, they were deemed "inappropriate and unnecessary" while I was having the major heart surgery based on the results of this testing. Things like this happen very frequently!)

Read her post very carefully. It is NOT the job of the doctor to appeal this for you, emailing the doctor asking him to appeal it isn't helpful. That's not what they do. Though you may, at a later date, have to get some information from him about why the particular procedure was performed when he got into it.

But just because someone quoted you in a letter and cited a policy or passage doesn't mean that your chances of appealing successfully are nil. Get hold of your dad's whole insurance policy, particularly the section about appeals. And follow those appeals procedures to the letter and chapter and verse. If your dad can't do it, get that POA and you work on it for him. If you are overwhelmed, try to find someone to assist you with it. But don't just say, "Oh well, they won't approve it no matter what! It would be useless for me to appeal!"

In my experience, as long as a bill is in appeal, and you're all working on it, payment can be deferred if the people you owe it to are in agreement. Stay in touch with the financial office of the hospital which is billing you for this, (NOT the doctor) and tell them what is going on. Talk to them, keep them in the loop, do not just ignore them, and usually they'll work with you or give you a bit of time until you can get things worked out with the insurance company. At that point, if it's an absolute no go, then start investigating financial assistance programs and payment plans and arrangements.

Most hospitals know that average people don't have the money to come up with payment for really big bills after surgical procedures like this. They want that insurance company to pay, because they know the insurance company has the money to pay. Many times the private individual doesn't, no matter how much they have harassed him or demanded he paid or sued him. Remember, for the hospital, their ultimate priority is to get their money.

And most insurance companies are peopled by folks who sit there all day and look at the submissions and pick up on whatever they can deny and deny it automatically and quickly. They have a program that gives them "chapter and verse" about the reason it should be denied. (One of my sons interviewed for a job like this, and he had no more medical expertise than a Labrador puppy!) But really, doctors don't tend to do extra work just for their own amusement or to stay in practice. If they thought it was medically necessary, the insurance company doesn't have such an absolute moral right to refuse it as you might think. They count on most people not appealing denials.

By the way, is your father on Medicare with a supplement, is that the kind of insurance that is refusing you, or is he still employed and carrying company insurance? Edit, just saw where you said he was retired, so this is a Medicare supplement insurance?

 

[michaerlscai]

First of all, your dad doesn't need to work himself into a tizzy about getting this paid. He needs to concentrate on getting better, and being thankful that his surgery was successful. As you said, it was totally out of his control, he has done nothing wrong, and it will eventually all work itself out. He's lucky to have you to help him and be willing to deal with this.


By the way, is your father on Medicare with a supplement, is that the kind of insurance that is refusing you, or is he still employed and carrying company insurance? Edit, just saw where you said he was retired, so this is a Medicare supplement insurance?

his surgery is successful so far. however because angioplasty was used, doctor has to use a different stent that can strech out the artery a bit.. (rather than a soft stent that conform to the artery).. from what my dad read, the risk of a angioplasty and heavier stent is it might cause the aneurysm to get bigger - because it streches the artery. And that add to my dad's stress because angioplasty and different stent was used - although the doctor said he only streched it 'a bit', and we have to take his word for it. he will know for sure in a few months when he go back for a follow up angiogram checkup.

I should clarify he is retiring, so he still have the health plan from his university where he is a professor for many years. he will be on medicare later this year.

It's good to know he should appeal and there is still chance of success. I will ask him to get a detailed policy.

thanks for the detailed reply!

 

[cbg]

Michael, there is just a chance that I might be able to be a great deal more help than I initially thought. Please PM me the name of the university where your father teaches. I may - not will, may - be able to see the policy directly. I work in the benefits office of a major university and have access to the plans of several schools.

 

[michaerlscai]

Michael, there is just a chance that I might be able to be a great deal more help than I initially thought. Please PM me the name of the university where your father teaches. I may - not will, may - be able to see the policy directly. I work in the benefits office of a major university and have access to the plans of several schools.

Thanks cbg, pm sent!

 

[cbg]

Hey, Michael - the school in question offers two possible policies. I need to know which one your dad is enrolled in. PM me the info on his ID card - not the ID numbers, just the name of the plan.

 

[cbg]

Okay, there's good news and there's bad news.

The good news is that the treatment in question is not specifically excluded. The bad news is that the policy expressly allows for even an otherwise covered procedure to be denied if it is inappropriate to the situation and the patient's care.

That means that your appeal needs to be based on the medical necessity of the procedure, which in turn means that you're going to need the assistance of the doctor for your appeal. He is going to need to convince the utilization review team that there was a medical necessity for the procedure if there is to be any chance of the insurance paying.

I was able to find a copy of the policy directly on the university's website. If you need help locating it or determining which one you need, PM me. You will need to get the policy to find the appeal process, and I cannot stress enough the importance of following it to the letter and within the time frames allowed.