Nevada Health insurance doesn't want to pay for my hospital bill

[Pcmaker]

Jurisdiction

Nevada

Long story, but I need some assistance figuring this out. Hopefully we have guys in here that are familiar with this industry.

6 months ago, I decided to see a hand doctor about my hand. I think it's carpal tunnel syndrome. It's been bugging me at work since I work maintenance, I turn a lot of screws and bolts. I've had this pain for a long time now. The doctor says that since I've had it for around 20 years, he recommends doing surgery. The doctor is In-Network. I saw a neurologist to do some testing and then the time came for surgery.

The surgery center is out of network, which is 50/50. I was going to back out, but the surgery center called me and the lady said I only pay $250 out of pocket. She reiterated this fact and I am now looking through my email to find the document.

Months after the surgery, I received a letter from my health insurance company denying the claim for the procedure because it hasn't been an effective way of treatment for carpal tunnel syndrome. They sent me this well after I've already had the surgery done. I thought the doctor would be in contact with the health insurance to make sure that the procedure is going to be paid by them, at least mostly. I forgot about the letter, this happened during the pandemic when a lot of shit was happening.

Fast forward to today, and I received a letter from the insurance company about an "appeal." I had no idea what it was about, so I called them up. The lady said it was about the surgery and the total was 40k, and I have to pay 38k out of pocket.

I haven't received any bills from the surgery center, so I don't know what's going on. I guess they were going back and forth with the insurance company trying to get them to pay.

I don't want to pay the $38k. The insurance I guess doesn't wanna pay, even though on the policy it says my maximum annual out of pocket is $8k.

This is complicated and Google is no help. I'm going to try calling the insurance company again and talk to a different lady. The one I talked to was no help and sounded like she just wanted to end the conversation ASAP.

Found the email about the 250. This is one of the pages out of 5

 

[cbg]

I thought the doctor would be in contact with the health insurance to make sure that the procedure is going to be paid by them, at least mostly.

That was your responsibility, not the doctor's.

he lady said I only pay $250 out of pocket. She reiterated this fact and I am now looking through my email to find the document.

Looking at the letter, the $250 is your portion only for the use of the facility. It expressly states that you may be responsible for other feels

I received a letter from the insurance company about an "appeal."

When the insurance doesn't pay for something and you dispute their findings, an appeal is what you do next. But it's up to you to file the appeal; if you don't file it, then their findings stand.

Just for your knowledge, AllianceMed is to other insurance carriers what McDonald's is to Ruth's Chris.

 

[Pcmaker]

I guess filling out the appeal form is my only course of action.

I've already paid the surgeon, the insurance paid most of it. The ones that the insurance doesn't want to pay is the surgery center. Basically the place that the surgery took place in.

How about the insurance policy of a maximum 7k annual out of pocket? Does that not count here?

 

[cbg]

Not when you use an out of network facility. An in-network facility has contracted to charge x amount for y type of service, and the limits you are responsible for are based on that. But an out of network facility has not signed that contract; if they had, they'd be an in-network facility. You are responsible for any charges the OON facility charges beyond the appropriate percentile that the carrier will pay.

You MAY, depending on your policy, have an OON OOP that is different from the in network OOP. But only someone who has read your policy can say if that is so and if so, what it is.

 

[Pcmaker]

That $250 waiver I signed is my only hope.


My in network is 70/30 and out of network is 50/50. Deductible is $1500, everything after that, it's either 70/30 or 50/50 depending on if it's in network or not

They make it so complicated. I talked to my health insurance before doing the surgery, too, to make sure everything is all good to go.

 

[army judge]

They make it so complicated. I talked to my health insurance before doing the surgery, too, to make sure everything is all good to go.

Talking is only a start.

Before you do anything, don't act on ORAL promises, act only upon a written proof (or your complete understanding of the contract policy). regardless, always seek writtn proof before doing anything. Never act solely upon the spoken word.

If you are unclear, seek clarification in WRITING from an authorized official, not a corporate drone.

If you are still uncertain or confused, do nothing, except seek another option.

 

[Pcmaker]

Is email just as good as a letter and it can come from anyone from the company?

 

[army judge]

Is email just as good as a letter and it can come from anyone from the company?

I don't like to use emails for anything BUT personal correspondence.
Make sure the email originates from an official, not some corporate drone.
That said, emails are better than oral promises.
Bear in mind, emails can be spoofed/faked, so be prepared to PROVE their authenticity (should legal disputes later aise).
There are services (for a fee) that can authenticate emails.
As in mist things, something is better than nothing.

I prefer old school, typed letters (or handwritten) sent via US Priority mail (or FedEx, UPS).

 

[Pcmaker]

Is it even worth appealing? How often do they reconsider?

Should I try and talk to the insurance people?

How about the surgery facility? Maybe remind them of the $250 waiver.

 

[cbg]

Let me try to explain the difference between in network and out of network using actual numbers.This is hypothetical and simplified; used for easy arithmetic.

In network facilities have signed a contract to charge no more than $1000 for service ABC. Using the terms of the policy you have discussed above, in-network a charge of $1000 would mean that you pay $300 and the plan would pay $700. 70/30 split That part is easy.

Out of network facilities have signed no such contract and are not bound by it.

For an out of network facility, the carrier will pay based on a percentile of the actual charges.There's a whole complicated formula as to how this is determined based on what all doctors in the same zip code charge for this particular service, but let's assume that they pay based on the 80th percentile of such charges, which is more or less in the general neighborhood of what usually happens. Let's say that the 80th percentile of what all doctors in the area charge for this service is $1200. If your policy pays 50% for an OON charge, then in this case your split would be $600 apiece.

But remember, the OON carrier has not signed any contract limiting his charges to $1000, or any other amount. If he wants to charge $2000, there's nothing that's going to stop him. There's a difference of $1400 between what the carrier has agreed to pay, and what the provider is charging. Of that $600 will show as your responsibility when the carrier sends you anything.

But what about the other $800? The provider doesn't have to write that off - he has no contract promising to limit his fees. The carrier doesn't have to pay it; they've already paid what their contract says they will pay.

Guess who's left? You are.

 

[Pcmaker]

I just talked to my insurance on the phone. He said that 6 days prior to the surgery, the hospital called my insurance and that they were told they needed preapproval to go ahead but I wasn't informed.

And the insurance guy on the phone said that the biggest thing is the "experimental drug" they used during the operation. He advised me to talk to the doctor who performed the surgery and ask him to do a retro pre-authorization and if that's approved, then I don't have to fill out an appeal form, but he said that there's no way they are going to pay for the "experimental drug" which I will also bring up to the doctor tomorrow. All I wanted was a carpal tunnel surgery and nothing else.

 

[cbg]

Then it sounds as if you need to be in touch with your doctor about the retro pre-auth.

It is SOP for an insurance carrier to exclude experimental drugs or procedures. Usually they are listed in the policy as not being covered and when that is the case, there is no force on earth that can force them to pay them. If your carrier is even suggesting that it might be paid for if you/your doctor does x, y and z, then you'd better do x y and z.

 

[Pcmaker]

Thanks.

I just talked to the billing company for the surgery center and she told me over the phone, which I wish I would have recorded, that I do not have to pay for anything, even the experimental procedure that the insurance company said they will definitely not pay.

They are also doing a retroactive preauthorization.

 

[PayrollHRGuy]

Thanks.

I just talked to the billing company for the surgery center and she told me over the phone, which I wish I would have recorded, that I do not have to pay for anything, even the experimental procedure that the insurance company said they will definitely not pay.

They are also doing a retroactive preauthorization.

That's great, I'm glad this worked out for you.