$65,000 Nightmare

[jillh1981 0]

Hello everyone,

I started my sleeve journey in August, when I was told my insurance company required 6 months of work with a dietician, as I'm sure a lot of people here have experienced or heard of. I did all that, jumped through all the hoops, and was sleeved March 7th. Fast forward almost two months, I just yesterday found out my insurance company does not cover the sleeve (??????) and I've now acquired $65K in surgery bills. I called the insurance company and the man I spoke to said they only cover diagnostic fees that come with it (whatever that means) and that was the end of that. I called the surgeons office in tears, and they said they'd never heard of anything like this, but that they got their money so the letters I received from my INS company must be "erroneous". After speaking with them today, they told me that even though the insurance company had reimbursed them, they just found out today that they are asking for the money back, and that they are going to appeal it. WHAT DOES THIS MEAN?! Has anyone ever had any problems of this nature? I went from only owing $2500 in deductables to $65,000!! I could've gone to Mexico and had a sleeve vacation for $10K! I am so beyond upset right now, and feel like my insurance company is trying to ruin my life. Please, any advice/stories/knowledge would be greatly appreciated.

[traceyc 89]

Wow, sorry you are going through this. Did the insurance provide you or your doctor a letter with your approval prior to surgery? I would start digging for a paper trail so you can fight this.

[jillh1981 0]

I rec'd a letter in Feb from the insurance company stating the surgery was a medical necessity. The surgeons office says they don't proceed without approval, so they aren't sure what's going on. What's weird is my ins. co has already paid everybody, but now they are taking it back. I didn't even know that was possible.

[2bsmallagain 156]

I would fight this because it is the physicians office responsibility to send info to the insurance company and make sure they are getting paid which sounds like what they did. The insurance company should know what they will pay for and if they paid then it is their error. That is crazy. I would find the approval letter like traceyc said. That will be your key to winning this battle. The letter the doctor sent to the insurance also will state the procedure and the approval letter should also. Good luck.

[Mr_Worm 129]

Time to lawyer up

[Mab 44]

That is insane. However, I have a feeling it will all work out in the end. Honestly, I would contact your local news. WLS has been in the news recently and with all the bad press insurance is getting these days, I bet they would love to do a story.

[Wheetsin 714]

This is a really sticky situation. At the end of the day, the patient has responsibility to pay for any services rendered - so first, do not accept insufficient explanations from your insurance company. You need to understand exactly what happened, and why. Often things like this happen because there's an employer-enforced exclusion that is either missed, or wasn't in the system at the time of pre-approval. Either way, you need to spend some serious time on the phone with your insurance company and find out EXACTLY what happened: is it an approved procedure, do you have any type of exclusion (as your HR dept too), when was the exclusion put in force, etc. DO not accept anything less than exactly the info you're looking for. If necessary, have a conference call between you, your surgeon's coordinator, and a manager at your ins. co. I've had to do that a few times for myself, and helped several people through the process. Don't be timid, shy, or back down. You have a right to understand what happened.

Even if pre-approved, there is no guarantee of payment. I don't want to be a bubble burster, but I'm already seeing a lot of people saying "it was preapproved so they have to pay" (or thereabouts). That's just not the case. That little disclaimer in bold is on virtually every phone queue waiting message, piece of paper you get, etc. from every medical insurance provider out there. Does that make it right? No. And it's not really intended for situations like this, but it's a pesky little loophole. That's how they get out of paying for mistakes like these. (Insurance companies can also go back and "change their minds" on something paid, and revert it to a blance owed... IIRC they can do this for up to 2 years.)

I would also speak to your surgeon. Those billings amounts are what they bill insurance companies retail, which is a GROSSLY inflated amount over what they usually charge self pay patients, and is NEVER the amount the insurance company actually pays. If nothing else, perhaps your surgeon's office can revert the bill to self-pay rates. Example:

Insurance company charged $57,000.

Insurance company pays $8450 (total of "contract" or negotiated plan rates)

Self pay rate: $12,300.

Feel free to PM me if you need more help. I have a lot of background in the insurance industry, and have been able to give people some advice that actually helps on occasion.

[jillh1981 0]

Time to lawyer up

Honestly, that was my first thought. But who would be sued in this instance? The Ins co or the Doc?? And, in the end I'm afraid it would turn into one of those "you should've known your own coverage!!"

[Joni 94]

OUTRAGEOUS!!! How dare them to do this to you at this stage of the game. I don't know legalities but I definitely see your insurance company in the wrong, and a fight you will win. Please don't let this upset you too much - it's not worth it when it's THEIR MISTAKE IF THEY PAID. I agree, call a lawyer and find every piece of paper you have. Good luck.

[NisaletOAM 48]

OMG I thought that when the insurance company sent the approval letter they could not go back on there word that's what I was told buy my surgeons office meaning once you got the approval it was final and they HAVE to pay and stick to there word. I have not been sleeved yet and this is nerve wrecking.

[Giselle3264 175]

I'm sorry to hear how this is stressing you out. I worked for a health insurance company for many years and, yes, they can rescind payment. HOWEVER authorization is often done using ICD-9 codes so if the procedure authorized was the one submitted for payment, I don't know why they're acting crazy. It's going to be a fight but the doctor and the facility will be there with you every step. They won't let this go down easily because when we rescinded payment, we took it out of future checks! Ugly!!! Don't let it stress you out!!! We (the insurance company) made many, many, many, many mistakes in my time there. I spent most of my time with claims appeals of things we did that were just stupid. And it often took us a while to realize it was stupid. Loved the people there but hated the process. Hang tough and enjoy life with your sleeve.

[Wheetsin 714]

No, not the case. It should mean that, but it is never a guarantee. It merely states that the insurer intends to cover the service, but on final review of the claim, they may determine the service to have been unnecessary (for example).

Kind of very scary, huh? They usually don't deny pre-approved claims/services, but it happens.

Get ready for a fight, but I think $65K is worth it. I know it's hard not to feel like the victim. Your surgeon's coordinators should advocate for you. If you have benefit access to a coverage advocate, use it.

OMG I thought that when the insurance company sent the approval letter they could not go back on there word that's what I was told buy my surgeons office meaning once you got the approval it was final and they HAVE to pay and stick to there word. I have not been sleeved yet and this is nerve wrecking.

[Sleeved&Hopeful 182]

I have to tell you I am SO sorry. I , too, agree that if you could have foreseen this happening you could have just gone to Puerto Vallarta and had the sleeve surgery and a lovely vacation. That is absolutely sickening that you are having to go through this. I was like the other poster and assumed that once the insurance company sent approval over, that it was said and done. I obviously don't know squat. I went to Mex to get surgery because I knew I couldn't get it paid for here in the U.S. I tell you this, if I ever need chemotherapy or radiation I am going to Mexico. I don't want to worry about paying for an insurance company in America back for something I thought was covered!

I agree that you should get a lawyer after you've tried getting on the phone with the insurance company. You should call them and ask them exactly what happen and why they are now going to ask for money back. If all else fails, find out how much the hospital charges for self-pay. I absolutely agree with the other poster who said that. If something bad happens and you do have to pay for it, you should be able to get it drastically reduced. This would be after you try to get a lawyer and see what you can get done.

[jillh1981 0]

No, not the case. It should mean that, but it is never a guarantee. It merely states that the insurer intends to cover the service, but on final review of the claim, they may determine the service to have been unnecessary (for example).

Kind of very scary, huh? They usually don't deny pre-approved claims/services, but it happens.

Get ready for a fight, but I think $65K is worth it. I know it's hard not to feel like the victim. Your surgeon's coordinators should advocate for you. If you have benefit access to a coverage advocate, use it.

You're right - my "approval"/medical necessity letter does state that this does not guarantee payment. If that was the case though, why did they pay everybody, only to now frantically demand it back?! That makes absolutely no sense to me. Or, better yet, how about they alerted me of this BEFORE my surgery?! Also, if these are the rules, and they can change their mind at any moment, then why do they EVER pay for ANYTHING for ANYBODY?! I can't wrap my head around this. I really thought MY insurance company that I've been paying for four years would be on MY side.

[Mr_Worm 129]

Honestly, that was my first thought. But who would be sued in this instance? The Ins co or the Doc?? And, in the end I'm afraid it would turn into one of those "you should've known your own coverage!!"

The Insurance company would be the primary party to sue since they led you to believe you were approved, sent you through the 6 months of hoops and wasted your time. Be sure to pull all documents you've received showing anything that showed approval or hint of approval.