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

[michaerlscai]

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.

What's the chance of the success with an appeal on these things? what's a rough percentage of success?

Also the financial office says they may reduce it, do hospitals reduce the bill a lot if insurance company won't pay?

Also what's the next step in the worse case appeal is not successful?

thanks again

 

[commentator]

Appeal first, worry about what your chances are later. From the sound of this, you're thinking maybe just go on, pay it off, etc, that it would be a lot of trouble, and after all the hospital might reduce it..... Do not fall into this way of thinking. Go for the appeal. The hospital isn't giving you a "decide right now" offer, no matter what they say. Sure, they'd like to have their money immediately. Whoever collects gets kudos, so they'll tell you just about any freaking thing to get you to pay right now.

What are the chances you'll be successful in the appeal? Well, I promise you they are zero percent if you don't appeal!!!

And as I said, surgeons do not generally do things just for their own amusement. If there was some really reasonable reason why the doctor used the procedure he used, once he got in there, without your father's consent, he should be perfectly willing to answer questions, provide documentation, work with you on this.

As I said, I have actually done 100%, I got both processes approved that I appealed for myself, and one where I assisted a family member with another situation, another insurance company. Most people just are unwilling to think of doing this, it's like homework to them and they'd rather not.

 

[cbg]

My direct experience with this is some years out of date and with a different insurance carrier, but as I recall at least 50% of appeals were successful. YMMV.

Yes, hospitals are often quite willing to work with you on the bill when you have an insurance denial.

Plenty of time to worry about the next step when you get there.

 

[michaerlscai]

the doctors office says they are willing to reduce the bill by 40%, which still leaves it at 6k.

the insrance policy actually has something states if a treatment is experimental, and provider didnt have something in writing, patient is not responsible for such charge.

my dad need to go back for a follow up angiogram in september, so this is a delicate situation..

 

[Dave1952]

Would someone tell me what "experimental' means in this case. I'd think that an experimental surgical procedure would requite an Informed Consent that has been approved by the local Institutional Review Board. This document would be different from the usual consent for surgery and anesthesia. If the patient had signed such a consent, I doubt we'd be here. If the surgeon did an unapproved experiment then he may be in real trouble from the hospital.
If the insurer is refusing to pay because the insurer defines this procedure as experimental then the rules may be confusing because there are experiments done in hospitals but this may not have been a hospital approved experiment. Courts do not like those who write confusing documents. I'd ask the insurer to show that the procedure was, in fact, an experiment.

 

[michaerlscai]

Would someone tell me what "experimental' means in this case. I'd think that an experimental surgical procedure would requite an Informed Consent that has been approved by the local Institutional Review Board. This document would be different from the usual consent for surgery and anesthesia. If the patient had signed such a consent, I doubt we'd be here. If the surgeon did an unapproved experiment then he may be in real trouble from the hospital.
If the insurer is refusing to pay because the insurer defines this procedure as experimental then the rules may be confusing because there are experiments done in hospitals but this may not have been a hospital approved experiment. Courts do not like those who write confusing documents. I'd ask the insurer to show that the procedure was, in fact, an experiment.

I don't know what the insurance company mean by that specifically, basically intracranial angioplasty (which streches the artery) is not commonly performed.

The doctor has said he will use a kind of soft stent that conform to the artery, but he end up using a different stent. He also said he will not do angioplasty, but end up doing it. The risk of angioplasty is it might cause further dissection and not helping the healing of the anuerysm after the surgery. Also because of angioplasty is used, he has to use a different stent that's harder than what he said he will use.

So while I understand the doctor has his reason of doing what he did, what he did do is different from the game plan. He should at least explain before hand that he might do this as a possibility. Because we consulted multiple neuro-surgeons and decided his treatment plan is the best. Had he told us he will do angioplasty and use a harder stent, we might have to think twice or decided differently. So I think the doctor is not without blame here. He basically took us out of the decision loop and performed something different as discussed. It seems to be pretty bad for him to do that without approval form the patient and the insurance company, and after the surgery say 'btw I did that'.

This puts us in this billing issue we are in right now and also causes additional mental stress because we aren't sure of his treatment which he said he wouldn't do.

My dad will request a statement from the doctor's office why the procedure is necessary so that he can appeal to the insurance company.