"The Guy" and the MRI - Part 2 (conclusion)
I left off my story about my MRI charge of slightly less than $4,000 because of The Guy who approves/disapproves medical procedures was M.I.A. for a few weeks for a vacation and refused to approve it when he returned (must not have been a pleasant trip). So rather than receiving the "official" pre-approval within the stated 72 hours, I received a bill within a few weeks and a notice that my insurance provider declined to pay any of the cost. Obviously, the specialist who ordered the test was not as qualified as The Guy to make that determination. Actually, since the results were now back from the MRI, there wasn't anything wrong, so it must have been an unnecessary test (if that logic begins to make sense, you should consider a career in medical insurance).
I appealed to the insurance company so after letters from my doctors and the results from the hospital justifying the tests, it was still denied.
So, I sent a letter to the company quoting their policies about what they expect from me and what I am entitled to expect from them; particularly about the 72 hour response. After reviewing that, they seemed to agree that they actually could have handled it better and paid all but a hundreds of dollars after deducting the "Reasonable and Customary" difference and the discount taken at the hospital. I paid the balance and felt somewhat justified. Somehow they still made me feel that they were doing me a favor.
Over a year later, I received a call from a collection agency in Texas about a $600.00 charge that was not covered with the Radiology group that performed the above test. I told the person that I would need to talk to that group, but they had closed to start another. So after receiving the billing paperwork I negotiated to a little over $300.00.
The reason for this detailed account is to try to explain how difficult it is to work within a private insurance policy. Group Policies are handled much better and you have people to talk to and have the clout of a large group of insured people.
Lessons learned:
1. "Not Reasonable and Customary for the area;" the corporate office of my insurance company is about 3 minutes from the hospital that performed the procedure. Will explain the complexities of R&C later. It has been changed to mean something entirely different from what I was told when I bought my initial policy.
2. I know many of the people who work at my insurance company and believe that they are good people and they think that they are doing the right thing. The training for working in Insurance involves some sort of rewiring the logic patterns of the brain and it makes sense to them. Also, to be totally fair, they have gotten much better over the last year in responding.
3. This is one of the more simple problems that I have have encountered over the years and it amazes me that a couple can easily spend $30,000/year (some years, much more) in insurance premiums and uncovered medical expenses every year without having something that kills you fairly fast or can be fixed.
I will include some other examples later, but will be moving into the area of what is happening with contemplated changes in Health Care and why some of these problems are our excessively high expectations and others are lack of understanding by most of our politicians and some simply greed.
You hear about the 47,000,000 who are uninsured, but not much about the millions of those who have private insurance or inadequate insurance, but that is for another time.
TVP
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I appealed to the insurance company so after letters from my doctors and the results from the hospital justifying the tests, it was still denied.
So, I sent a letter to the company quoting their policies about what they expect from me and what I am entitled to expect from them; particularly about the 72 hour response. After reviewing that, they seemed to agree that they actually could have handled it better and paid all but a hundreds of dollars after deducting the "Reasonable and Customary" difference and the discount taken at the hospital. I paid the balance and felt somewhat justified. Somehow they still made me feel that they were doing me a favor.
Over a year later, I received a call from a collection agency in Texas about a $600.00 charge that was not covered with the Radiology group that performed the above test. I told the person that I would need to talk to that group, but they had closed to start another. So after receiving the billing paperwork I negotiated to a little over $300.00.
The reason for this detailed account is to try to explain how difficult it is to work within a private insurance policy. Group Policies are handled much better and you have people to talk to and have the clout of a large group of insured people.
Lessons learned:
1. "Not Reasonable and Customary for the area;" the corporate office of my insurance company is about 3 minutes from the hospital that performed the procedure. Will explain the complexities of R&C later. It has been changed to mean something entirely different from what I was told when I bought my initial policy.
2. I know many of the people who work at my insurance company and believe that they are good people and they think that they are doing the right thing. The training for working in Insurance involves some sort of rewiring the logic patterns of the brain and it makes sense to them. Also, to be totally fair, they have gotten much better over the last year in responding.
3. This is one of the more simple problems that I have have encountered over the years and it amazes me that a couple can easily spend $30,000/year (some years, much more) in insurance premiums and uncovered medical expenses every year without having something that kills you fairly fast or can be fixed.
I will include some other examples later, but will be moving into the area of what is happening with contemplated changes in Health Care and why some of these problems are our excessively high expectations and others are lack of understanding by most of our politicians and some simply greed.
You hear about the 47,000,000 who are uninsured, but not much about the millions of those who have private insurance or inadequate insurance, but that is for another time.
TVP
Posted by The Virtual Patient at 2/23/2009 4:46 PM 
Categories: Pre-certification, Reasonable and Customary, Insurance, Appeal denial, Pre-approval
Categories: Pre-certification, Reasonable and Customary, Insurance, Appeal denial, Pre-approval
Interesting article. Thanks for the posting.
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