can insurance co's change their decision to cover & not inform you?

[tressmess]

What is the name of your state? NY

Can an insurance company agree to pay for a MRI, issue a referral number, and then change their decision without informing the insured?
A good friend of mine had an approval to get a MRI with a ref. #, had the test done, and started receiving bills almost a year later with threats of being sent to collections. Her doctor said the insurance company is entitled to change its' decision. Aren't they under any obligation to notify the insured of said change? Maybe she wouldn't have had the test done at that time, as it costs over $800 and is self-employed as a massage therapist, with fluctuating income. She had to pay the radiologist in order to avoid ruining her credit, but does she have any recourse?

 

[Beth3]

If the bill for the MRI was sent to the carrier, I expect they would have sent an EOB (Explanation of Benefits) form to your friend, showing the charge and the denial. What your friend needs to do, if it's not too late, is to file a written appeal with the insurance company and request a review of their decision. Information on how to do that will be in the Plan Document/insurance booklet.

 

[lkc15507]

What is the name of your state? NY

Can an insurance company agree to pay for a MRI, issue a referral number, and then change their decision without informing the insured?

Yes. An insurance plan must pay according to the plan description. Even if a representative of the plan inaccurately approves a service, if the service is not covered by the plan as described, it (the service) is still not covered, regardless. The 'plan' is a contract. That contract must be observed as written. (This is not meant to address how such inaccurate information may allow one to recover any damages. --See below.)

Usually, a 'pre-authorization' is based simply upon 'medical necessity'. When such an authorization is given, it is still subject to all other provisions of the plan--such as eligibility, status of the insured at the time of service, deductibles, copays, coinsurance etc etc etc. Even then, determination of 'medical necessity' is subject to change upon a review of complete medical records surrounding the event.

If such a disagreement should go to court, the determining factor would be whether misinformation / information was given in order to intentionally avoid payment of the claim (very simplified). A plan description should be available to every covered member to read and understand--ie, the safeguard against being treated incorrectly. It is ultimately the responsibility of the insured to know coverage.

If one does not have such a plan description, I recommend starting with a request from HR and follow up with a complaint to the Department of Labor if not received timely. (DOL may not be regulating body for your particular plan, but start here, they WILL tell you the correct place to go if they do not regualate the particlar plan.)

As far as notification of 'adverse determination' is concerned, every claim processed should result in an EOB (Explanation of Benefits) form. This form, a denial of payment and 'advserse determination' would likely be all that is required, even with a 'preauthorization' of the service. There would be no requirement to notify an insured 'in advance' of a denial because all coverage criteria would be covered in the 'plan document/description'.

Now, specifically, an MRI as an outpatient would likely be covered under most plans I am acquainted with--as long as there is a medically necessary reason to perform the test. I think that most times that reason would be readily explainable. I suggest to your friend to read the plan description and make sure that the claim is a valid claim and submitted according to the terms of the plan.

Good luck to you and your friend,
lkc15507