Question
What is the name of your state?What is the name of your state? California
My wife has been in agony with varicose veins twice over the last 5 years. These two previous vein stripping surgeries provided some temporary relief but the pain came back early 2004. We looked into the Endovenous Laser Therapy since the other two surgeries didn't provide good long term results.
The surgeon's office staff called the PPO for preauthorization and was told "not required" if it was medically necesary. After the invoices($5,000 surgeon /$12,000 surgery center) were submitted to the insurance company it was denied .... "not medically necessary".
We are in Stage I of appeal with Cigna. Should the appeal be denied again what would be the best course of action?
Appeal - Stage II ?
Pay the $17,000 and shine it on ?
Litigation?
Thanks for any assistance (sorry for the long winded explanation)
Answer
There are usually several phases of the internal appeal process with the insurance company. The only thing that costs you is time. If you have the time to wade through the appeal process, it's probably worthwhile because you have nothing to lose and a lot to gain.
"The surgeon's office staff called the PPO for preauthorization and was told "not required" if it was medically necesary." That simply means that they don't issue preauthorization numbers for services you wish to have. They don't make a determination of medical necessity in advance of services. That's just an explanation of how their claim system works with their PPO holders, which is explained in your insurance policy. If you wanted to know if it was going to be covered, you could have called the insurer before the services were rendered and find out if the proposed treatments would be considered medically necessary in light of the patient's condition(s).
Litigation? I don't know where you're going with that. An insurance policy is a contract. An insurer is free to determine what it will pay and what it will not. If the coverage was not to your liking, you were free not to enter into the contract. Once you did, you cannot force the insurer to change the terms of your contract. You can try, via the appeal process, but you can't force them to change their coverage rules.
It is always the patient's responsibility to ensure prompt payment. Having insurance doesn't change that. I strongly recommend you pay your bills when you receive them, or work out payment plans with your service providers if you can't pay it all at once. Even if you win an appeal, bills paid late still have a negative effect on your credit and accrue late charges/interest.
Answer
Thanks Purple2 for the reply. Maybe I'm toooooo pessimistic but we'll see how phase I of arbitration goes. Should get a reply in 2 weeks or so.
Will discuss with the doctors staff tomorrow where we stand with arbitration and payment.