conversation
after getting thru the electronic system, intentifying myself to the rep and giving her the patient ID, the date of service and the amount charged
"We received a copy of the Explanation of Benefits for this claim today, and it says it was denied because it is not covered under this patient's plan."
"Yes."
"I am a little confused, because we know that many plans don't cover this procedure code so we call to verify first. On December 9, I called this number and spoke to Marla at 1:55 pm, and she told me that it was covered at 90% of the contracted rate."
"Hold on."
a few minutes on hold
"This code is subject to medical necessity."
"Yes, did you receive the Letter of Medical Necessity that was sent with the claim?"
"Yes and it was not deemed medically necessary. You can appeal this decision to our Appeals Department."
"Well, we have had cases when there is a decision made that something wasn't medically necessary and we have gone through the appeals process, but in this case we've been told that it is just not covered under the patients plan."
"Because it's not medically necessary."
"But the Explanation of Benefits doesn't say that. It just says it is an exclusion of this plan. When something is found to be medically necessary we receive a denial that says that."
"You received a denial."
"Yes, but I need something in writing that says it was denied for not being medically necessary.
"It was denied and I just told you it was because it wasn't medically necessary."
"But I can't appeal this based on that. There needs to be something in writing."
"Well, we can't send you anything."
"Then I can't appeal it and I just have to bill the patient."
"Just do whatever you have to do."
hangs up
This conversation took place on the very day I decided to create this blog. We both were becoming increasingly frustrated and loud. Afterwards, I called back and got a different rep who confessed to being baffled as to why this claim was denied and amazingly admitted that this was never deemed medically unnecessary. She sent the claim back to be reviewed with an extensive note attached to it explaining the situation.
If I had to bet, I would say this will come back with an official denial stating it is not considered medically necessary and you can appeal by sending the required documents to.....
There is a lot more to say, but I will have to say it in later postings. I don't want to give away the ending, but you, the patient, are most likely going to be screwed.
"We received a copy of the Explanation of Benefits for this claim today, and it says it was denied because it is not covered under this patient's plan."
"Yes."
"I am a little confused, because we know that many plans don't cover this procedure code so we call to verify first. On December 9, I called this number and spoke to Marla at 1:55 pm, and she told me that it was covered at 90% of the contracted rate."
"Hold on."
a few minutes on hold
"This code is subject to medical necessity."
"Yes, did you receive the Letter of Medical Necessity that was sent with the claim?"
"Yes and it was not deemed medically necessary. You can appeal this decision to our Appeals Department."
"Well, we have had cases when there is a decision made that something wasn't medically necessary and we have gone through the appeals process, but in this case we've been told that it is just not covered under the patients plan."
"Because it's not medically necessary."
"But the Explanation of Benefits doesn't say that. It just says it is an exclusion of this plan. When something is found to be medically necessary we receive a denial that says that."
"You received a denial."
"Yes, but I need something in writing that says it was denied for not being medically necessary.
"It was denied and I just told you it was because it wasn't medically necessary."
"But I can't appeal this based on that. There needs to be something in writing."
"Well, we can't send you anything."
"Then I can't appeal it and I just have to bill the patient."
"Just do whatever you have to do."
hangs up
This conversation took place on the very day I decided to create this blog. We both were becoming increasingly frustrated and loud. Afterwards, I called back and got a different rep who confessed to being baffled as to why this claim was denied and amazingly admitted that this was never deemed medically unnecessary. She sent the claim back to be reviewed with an extensive note attached to it explaining the situation.
If I had to bet, I would say this will come back with an official denial stating it is not considered medically necessary and you can appeal by sending the required documents to.....
There is a lot more to say, but I will have to say it in later postings. I don't want to give away the ending, but you, the patient, are most likely going to be screwed.
posted by sparklestone at 3:49 AM
1 Comments:
I found your blog interesting. I've worked in the insurance industry for 14 years. You're complaints can only be attributed to your lack of understanding the insurance industry. An offer is submitted for reimbursment. We have had to create a list of generally accepted rates associated with the medically recognized procedures which you reference. When the benefits coverage plan sets a rate and no one in the medical profession recognizes that it already contains a professional service premium then they object when they don't get a qualifying benefits reimbursment. If you take the average rider on most of these policies, you see that the medicaid rate is nearly identical to the medically necessary rate acknowledged within the insurance industry. Good Luck.
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