Tricare denied claim after approving surgery!

[onebadkitty 0]

I was called by Tricare to tell me that my surgery was approved, Yeah! I went in for the surgery at the hospital and they told me I was clear and didn't owe anything for the surgery there. I assumed they had gotten approval through Tricare as well. I went on TricareWest online and to check my claims and found that Tricare had denied a $2000 claim by the hospital. It says patient responsibility $2000! They said that I was approved. Has anyone got any experience with this? I am so worried, this was sooo not in the budget! What will happen?!

Need advice please!

[Rainydayz 3]

Did they say you were approved for 100%? If not that may be your portion if you have to pay say 10-20% of the cost.

Otherwise it could just be that they haven't finished doing all the billing and discounting that providers do with insurance companies. I know sometimes I will get a bill from a doctor and I'll call them about it and they say to wait until the insurance has finished paying. They will negotiate prices with them and sometimes the bill goes out automatically before all that is done. Don't stress. If you really need to find out then call the hospital billing and ask what the status is and if the insurance has paid all they are going to. Good luck. I know unexpected bills can be stressful though.

[onebadkitty 0]

My husband is active duty military, so we are on Tricare Prime so ALL of our care should be free to us as long as we are approved for services. I was called by the person approving my surgery and she only said that I was approved. The claim for my Dr. was paid in full at the price that he quoted me. While a claim to some other person was denied. I am going to assume that that person is the anesthesiologist that was there for my surgery. It wasn't for the hospital I don't think.

[Dave_NW 92]

It may be how Tricare was billed. For example, they don't pay for Nutritionists, even if they work for the surgeon. If you had a NUT who billed Tricare directly for services, it may be disallowed. You need to review the claim itself on the Tricare website - it will break down the specifics of the claim, so you can see what it was for. If it was billed in error, the surgeon's office needs to resubmit the bill with the right billing code. If it was billed correctly but is for a non-covered service, you may be stuck paying it. I have Tricare Prime, and I haven't paid for anything more than a few office visit copays and the overnight in the hospital. You need to look closer at things.

Good luck!

Dave

[onebadkitty 0]

It may be how Tricare was billed. For example, they don't pay for Nutritionists, even if they work for the surgeon. If you had a NUT who billed Tricare directly for services, it may be disallowed. You need to review the claim itself on the Tricare website - it will break down the specifics of the claim, so you can see what it was for. If it was billed in error, the surgeon's office needs to resubmit the bill with the right billing code. If it was billed correctly but is for a non-covered service, you may be stuck paying it. I have Tricare Prime, and I haven't paid for anything more than a few office visit copays and the overnight in the hospital. You need to look closer at things.

Good luck!

Dave

I bet the anesthesiologist isn't a Tricare provider, the claim was clearly a person's name and not a facility. I hope they are ok with payments cause they should have told me ahead of time. The admissions lady sat down with me and told me that I was good to go and didn't owe any charges prior to surgery that morning. When you are told there are no charges it seems wrong to then say that there are, so sry. This is certainly not what I wanted, but I am not unhappy I had the Lap Band done. Worrying about it right this second won't help anything is what my husband says.

What are they gonna do? Come and take it out! LOL.

[eadreel 0]

It could also be that they used the wrong billing code when they submitted to Tricare.

ETA: My whole hospital bill was denied two times while the hospital figured out Tricare billing codes.

Also the only out of pocket with Prime for me is the nutritionist.

[jenn79co 13]

That happened to me also.

Eadreel is right, it's a problem with the codes.

it was an easy fix I just called billing at my hospital and explained that I was Tricare active duty and I should have been covered 100%. They said they would check the codes and get back to me. I think it was a day later I called tjem and they had resubmitted it. It went through no problem.

[honk 780]

It very well could be the anesthesiologist. After reading several stories like yours I asked specifically about that when I met presurgery with a member of the anesthesia group. He told me that some hospitals contract out that dept to another company. So they and the hospital are two different companies and the hosipital is an approved vendor to the insurance but the anesthesiologist is not! That's crazy in my opinion. I recommend people specifically ask their hospital is the anasthesia group is a dept of the hospital or seperate entity.

If that is your situation I would call this company and tell them you thought they would be covered under you insurance and ask them for a cash pay price. Most medical vendors state a price to insurance knowing they will only get paid 1/2. I would try to get them down to $1,000 since that's what an insurance company would have paid them.

[Cocoabean 430]

I may be wrong, but if it isn't a covered service (which seems strange, how do you have surgery without anesthesia?) As long as you make a payment, even if a dollar a month, they cannot turn it over to collections or affect your credit. I'd not start on payments until you know for sure though.

I am not Tricare, but as an example, I broke my wrist when I was out of my plan area. I kept getting bills for the emergency room visit. It went to a collections agency. I refused to pay, explaining that I was covered. The hospital wanted me to make a payment to them and recoup from my insurance. I declined. As I could prove I had coverage, they put the collection in abeyance until my HMO got their heads out of their you-know-whats, so it would not affect my credit.

My company kept telling me it was in "utilization review." Turns out that with my HMO when a bill is less than $500.00 the medical group pays it, over that the insurance co. pays. My bill was $495 and out of area, so they were wrangling over who was going to write the check. They finally figured it out and paid the bill.

[Humming Bird 275]

I was called by Tricare to tell me that my surgery was approved, Yeah! I went in for the surgery at the hospital and they told me I was clear and didn't owe anything for the surgery there. I assumed they had gotten approval through Tricare as well. I went on TricareWest online and to check my claims and found that Tricare had denied a $2000 claim by the hospital. It says patient responsibility $2000! They said that I was approved. Has anyone got any experience with this? I am so worried, this was sooo not in the budget! What will happen?!

Need advice please!

I am no insurance expert, but when all the billing gets complete, the hospital (or whoever) may just have to "write off" that $2000. They have to stick to whatever deal they have with tricare. They have not told you that you owe $2000 or billed you directly, correct?

[onebadkitty 0]

I am no insurance expert, but when all the billing gets complete, the hospital (or whoever) may just have to "write off" that $2000. They have to stick to whatever deal they have with tricare. They have not told you that you owe $2000 or billed you directly, correct?

No I haven't gotten a bill yet. I had just decided to check on my claims because I got an email saying they were ready. I have had that problem of the insurance not paying on a x-ray from and er visit because of a birthday or a social being wrong when they submitted payment. I just refused to pay, since it was DEF emergent I knew Tricare would eventually pay. I know now maybe I am freaking out before I need to, I just obviously didn't need the added unplanned expense. Though I KNOW if I was self pay it would be far greater than this amount and I should be thankful it is not more.

[eadreel 0]

You can always print out the billing page (If it isn't resolved in a couple of weeks) and take it to your Tricare office on base and I would say, toss a fit, but tell them they are paying, especially if you are AD Prime.

[lovemysgt 4]

i think it has to be billing i have Tricare Prime and i everything was paid for even the nutritionist

[AquarianCrab 8]

I don't think you're under any obligation to pay anything until you actually receive a bill. That said, my sister works at a hospital and tells me that billing makes errors typing codes in all of the time. I have Horizon BCBS, and I told them I wanted everything spelled out in writing before I started the "program". I received my approval in writing, with everything spelled out as to exactly what was covered and what wasn't. They even stated how many pre-op visits to the doctor and nutritionist would be approved, what pre-op tests, everything. With written approval in hand, I began my journey.

[cheryl2586 3,053]

If you havent gotten a bill then dont worry. Why worry about something you dont have yet.

Relax it will all take care of its self