Know your insurance coverage

[ldawn 178]

Let me tell you what happened yesterday. A little background...I work for a hospital. I’m also a very new employee here and recently read my summary of benefits and already had an idea of what my expected payment would be. One of the features of my insurance is that if I have surgery (or anything) at my facility with a staff doctor then there is no deductible and my copay is 15% for surgery and $35 for specialist office visit. I made my first surgeon consult appt for Thursday. I get a call yesterday from their insurance specialist about my benefits/expected payment. She said my insurance has a special $2000 deductible for bariatric surgery that applies to the surgery and all office visits related to the surgery. My consult will be $226 and I will have to pay full amount for everything until the deductible is met then my 15% copay of the surgery. I was shocked. I went home and pulled up my summary of benefits and reread it.

This morning I spent an hour on the phone w Cigna. They initially told me the exact same info the insurance specialist had been told. I explained what I found in my summary of benefits. She was able to see my summary of benefits herself and said my actual policy did not match it. She ended up calling the person at Cigna who is the main rep for my hospital system. Turns out, someone had chosen the wrong selection when putting the package together in their system. My information was correct. No deductible required. They will correct it issue in a few days.

I work for a very large hospital system. I asked the Cigna rep what about people who already had their surgery this year and paid the deductible? She said she didn’t know what would happen. I then called the insurance specialist at my surgeon’s office and told her the story. She said they see a lot of people from the hospital. She also doubts the hospital will refund any money to them.

So, know your benefits. Do your own research. Don’t be afraid to ask questions. It may save you a lot of money. It could also be the difference between having the procedure or not.

[KCgirl061 1,533]

Good call asking those questions, hopefully many can benefit from your looking into it at your hospital.

[ChellNC 162]

Great job getting them to catch their mistake and to correct it. The insurance specialist or someone at the surgeon's office needs to ask Cigna to do a claims project & reprocess all claims since the incorrect update was added to their system. If they reprocess the claims correctly the hospital has no choice but to refund the patients.