insurance denies claim

[siliconmary]

What is the name of your state? What is the name of your state? Kansas. I had breast cancer surgery in November 2000. My plastic surgeon who did my reconstructive surgery did not bill my insurance company until November 2002. My insurance company has denied this claim twice based on the fact that my policy has a one year filing deadline. Do you think the surgeon will try to come after me next. The insurance company has told her that she can't because it is not my responsibility to file the claims. What do you think?

 

[lkc15507]

siliconmary,

This is not what you want to hear, but the insurance co can deny the claim based on timely filing limits. And, unfortunately, it is the ultimate responsibility of the insured to ensure that all claims are timely filed, not the physician. Most people depend on their practitioners to file claims. That is the norm. However, again, the liability for the costs remains the burden of the insured. The health plan offers reimbursement for eligible services when the terms of the plan are followed, including timely filing limits.

But, now, what to do. Read and follow the terms of the health plan's appeal process. It is not impossible for the plan to make exceptions (but realize there may not be an incentive for them to do so.) Also, talk to your physician. Ask the physician to refile the claims on your behalf with an appeal explaining if there was a reason for them to not be filed earlier. I have known (although not the norm) facilities and / or practitioners to write off fees when their mistake is obvious.) If these channels do not work, then, seek the advice of a professional. Just one tidbit, there are regulations concerning breast reconstructive surgery. This is an area that public opinion and even the law recognizes as a right for affected women. Rattling cages just might obtain the result you need.

(Also, re the ins co telling the physician she cannot collect: to the best of my knowledege that is erroneous, and I suspect they are trying to pressure the physician into writing off the charges. However, there may be particulars regarding the type of plan and who regulates, ie federal or state, of which I am unaware.)

I hope the best for you.
lkc15507

 

[CIAA]

siliconmary ,

The insurance company may not be able to maintain their denial in spite of the claim filing time limit. The time filing provision is allowed in order to protect insurance company from claims that cannot be properly and satisfactorily proved up. Many states require that to enforce the late filing provision the insurance company must be able to prove "prejudice"; that is, that the payment of benefits would be mere guess work. Be sure to file your appeal asap as there may also be a time limit on appeals.

 

[siliconmary]

Thank so much for your suggestions. The fact is the doctor has already appealed to the insurance carrier twice and twice been turned down. The insurance is not a nationally recognized company but rather insurance that is only available through a Union, and is owned and operated by that Union. I received a letter from the Union(insurance) stating that the doctor can not come after me. I am torn between two thoughts, I am very grateful to this doctor for my reconstruction and feel like that I do owe her my co-pay which is 10% of the cost. But I don't know what that cost would be, before or after write offs. I guess I need to wait until the doctor makes her third and final appeal and then try to work out some type of deal with her. I feel an obligation but also feel like she is partially the blaim for not filing this claim in a timely manner. Again thanks for all your help.....Silicon Mary