I recently had hip surgery. Before the surgery, I confirmed with both the doctor and my insurance that the surgery would be covered by my insurance. No my insurance is claiming it's not covered.

I recently had hip surgery. Before the surgery, I confirmed with both the doctor and my insurance that the surgery would be covered by my insurance. No my insurance is claiming it's not covered.
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#1

What can I do to defray the $50k cost of surgery? Is there any way to negotiate with the insurance company?

I’m on COBRA with an Aetna PPO plan and had hip surgery recently. I did all the due diligence with my insurance and the doctor’s office to make sure it was covered in advance. Aetna even told me a couple weeks in advance it was covered when I called the insurance directly. Then, the day prior to surgery, I called Aetna about something unrelated and they indicated that my surgery would probably not be covered because it is considered experimental. It was too late to cancel the surgery after all the prep work and stress I was going through, not to mention family having already flown in from far away. I am now facing in excess of 50k in medical bills. My doctor’s office is appealing. I am young and was in pain just from walking. I had 2 doctors read my MRIs and they determined surgery was the only way to get better. Please help! is the doctor’s office responsible for telling me it was all approved by my insurance in advance when they did not properly do the due diligence? What else can be done? Thank you!


#2

Whether it is covered is irrelevant. A covered benefit does not mean it is payable for everyone, under any circumstance.The important question is was any authorization requested?

A surgery, especially if elective, usually requires a pre-authorization from your insurance.

That is the surgeon's job to obtain. Appealing the insurance company is within your rights, however your chances of success depend on your policy and wording on your insurance Explanation of Benefit. 

If your policy states an authorization was required but not obtained, you are likely out of luck. Again, depending on the surgeon's "mistake", you may be able to appeal and ask for a retro-authorization. 

If the denial is: "elective" or "experimental" procedure, and an authorization was not required, then you have great chances of obtaining a reversal. What you need is to establish the "medical necessity' for the procedure, including previous less radical but unsuccessful treatments, list medications that did not work or that provoke side effects, physical therapy or any other modalities which were not helpful. Any MRI report or medical report from a specialist, determining that the only and last treatment option was this surgery, should be included. Your surgeon should provide you with this documentation, and file an appeal as well. 

If your appeal is denied, and depending on the state you reside in, you may be able to file a complaint or ask for an independent review through the insurance commissioner's office. Check your policy too for steps to file a second degree appeal. 

If all fails, you should negotiate lower fees, especially if neither the surgeon nor the facility checked on the requirement to get an authorization. 


#3

I have never heard of a hip surgery to be experimental so I would need more information on that. But here are the steps you should take:

1. Request an itemization of the bill.

 2. Contact the Insurance Company and get the name of the Medical Director or head to the Utilization Department at the Insurance company.

3. Write a written Appeal. Send it certified mail or return receipt with a copy to the the Doctor and if you are insured with a PPO plan I would send a copy to the Department of Insurance, Department of Corporations or Insurance Commission (depending on which requlators oversee claims). This will delay action on this account for 60-90 days while it is investigated.

4. Research the Medicare Fee Schedule on line. Although you may not be covered by Medicare it will give you a guideline on what is a "reasonable" amount in reimbursement.

5. If you feel overwhelmed or unable to do these steps on your own, you could hire one of many "Patient Advocates" that can assist you with this process.   

Good Luck let me know if you need any additional information.


#4

Before you do ANY negotiating with anyone, this claim needs to be paid by your insurance. I am assuming that your doctor went thru the proper channels and had the surgery pre-certified. All that does is determine if the surgery is medically necessary. It does NOT guarantee payment. The rule of thumb is if there is no pre-certification, it is very difficult or next to impossible to get the  claim paid. if you have pre-certification, you MAY be able to get it paid. With that being said, you need to verify that authorization was obtained if needed. if it was not needed, then your doctor should have the name of the person they spoke to in the Utilization Management Department and a reference number. Then, you need to write an appeal to the insurance. An appeal consists of a well written letter explaining why you believe your insurance should be covering the procedure, and supporting documentation that supports the facts laid out in your letter. Send this appeal certified return receipt to the appeals department of your insurance. Allow 30 days from their receipt of the appeal. then call them for status. if your appeal is denied, you will need to go higher: Department of Insurance or the Dept. of Labor, depending on the type of insurance you have. I have done several appeals for experimental treatments that were denied by the insurance and won them all. You have a very high chance of success, but the appeal must be done properly.

if you have any questions, please reach out to me at 732-640-1006. Good luck. 


#5

I would hold the doctor and the hospital responsible because they should not have not proceeded with the surgery without authorization. If in fact authorization was in place then an appeal to the insurance company needs to be done by both the hospital and the provider.
If you need assistance please do not hesitate to reach out.
Cheryl Welch, MBA
Hudson Valley Medical Bill Advocates


#6

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