Heath insurance companies are no fun to work with

As I mentioned several months ago, I had issues with coverage denied for a brain MRI but it seemed to all get sorted out.  I don’t think I mentioned in the last post that the final person I spoke to said it was clearly marked in their system that I am not responsible for the bill and that it was the hospital’s responsibility to obtain approval.  I told that woman that my own paperwork said I was responsible, but she said not to worry as her system said I was not.

Fast forward a few more months and I get another notice in the mail saying that the claim was denied and I was responsible for the nearly $4000 bill.  It says that I did not follow proper pre-authorization.  I feel like I’ve been here before.  Within a few days, I receive a bill from the hospital wanting payment.

I go ahead and again call my insurance company and they tell me that the reason pre-authorization was my responsibility was because the hospital where I had my MRI was not “in-network”.  I told her that I had checked in advance and was told it was in-network.  She looks into a few things and asks the name of the hospital.  I tell her, and she says that the hospital is in-network and therefore the hospital contract says the hospital is responsible for the prior authorization and I am not going to be responsible for the claim.  She types a few more things and says that the computer shows a different name for the hospital and that this hospital is not in network.  I told her it is the same hospital – they just changed names within the past year.  She said the old name shows they are still under contract and therefore they are still in network.  The confusion was partly caused by the new hospital name not showing in their system as in-network.

One of the most disturbing things to me is that they are still denying the claim – saying the hospital has not shown medical necessity.  It seems ridiculous to me that their normal way of approving medical necessity is after the fact, and they are this rigid with wanting proof of necessity on a brain MRI ordered by a neurologist.

All I can say is that I hope they ultimately cover the test and the hospital gets their share.  At this time I’m not even responsible to pay my co-pay – which at 10% is almost $400.  My guess is if the insurance company eventually covers the test, it will be with a negotiated rate that is half of what the bill states, meaning my co-pay will wind up being closer to $200.  I have no problems whatsoever with paying my co-pay.  The hospital should get paid for the services they provided.

Hopefully I won’t hear anything about this until coverage is approved and I’m only going to have to pay my co-pay.

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