Question
What is the name of your state? PA
Hi,
I live in PA, but the problem is with a hospital in New York state.
My husband had high-tech radiation treatment that was denied by our insurance company as being "experimental". On our behalf and request, the hospital requested an appeal of the denial. The denial was upheld by the insurance company. However, no one ever informed us of this fact.
The insurance company says that when a provider initiates an appeal, the insurance company's responsibility is only to inform the provider of the decision. The hospital says that the insurance company should have informed us as well. Had we known about the denial, we would have absolutely preserved our legal rights by exhausting all the appeals allowed by law.
Now, we are beyond the 45 days allowed by law to request a second appeal. This treatment (which I firmly believe should be covered and, I think, would have been if the hospital had gotten a letter of explanation from the treating physician) cost $10,000, which we obviously do not want to have to pay out of pocket, as we are a young family dealing with the primary earner totally disabled.
I am having trouble getting anyone at the hospital to talk to me, other than the billing reps who answer the phone and have no real authority or answers.
So, I am wondering who is responsible for notifying us? If the hospital made the mistake of neglecting to file a second appeal, what recourse do we have against the hospital to avoid getting stuck with this expensive bill? Since the second appeal was never filed, have we lost any legal right to get the insurance company to pay this? (I am guessing the answer is "yes" to that one, from my novice knowledge of ERISA).
Thanks in advance for any insight, information, or guidance you can provide!What is the name of your state?
Answer
Why didn't you get approval before the treatment?
Answer
Our insurance does cover this procedure for my husband's diagnosis. It is a very high-tech, focused, and precise beam of radiation that is necessary for certain types of tumors.
The hospital billed it under a different name, and the insurance denied it b/c it is NOT covered under this incorrect description.
I specifically told the hospital that they had coded this incorrectly. They obviously did not state their case very well or fix the error.
BTW, this procedure was done at the world-famous cancer hospital where it was pioneered. They knew that this was medically necessary and proven to work for my husband's diagnosis, by peer-reviewed scientific research. The insurer specifically has a Policy Bulletin that says that it is covered. In my mind, the billing dept messed this whole thing up.
Again, I am unable to find the law in my searches online. Either the hospital or the insurance company made the mistake of not informing us of the denial, in turn denying us our legal right for a second appeal and leaving us stuck with an unpaid, expensive procedure.
We may need to consult an attorney to find out the answer, but I would love to know if anyone has any initial guidance or experience with this issue.
Thanks!
Answer
They cover it because you read it in the policy book? Or, they cover it because the insurance company was contacted PRIOR to the surgery and it was pre-approved?
Answer
This is not surgery, but a highly focused radiation treatment, and very specialized. It is only performed at a small # of specialized cancer hospitals. It is not listed in the "handbook," as this is far from being a run-of-the-mill cancer treatment that many people would have done. Our insurance has covered every other surgery, chemo, hospitalization, etc, for my husband. We, personally, have never called for "pre-approval" for anything. We have a traditional indemnity plan that, other than this one thing, has been excellent and given us coverage at the many hospitals we have consulted.
As I mentioned, the insurance company has posted publicly, online, their policy bulletin that clearly indicates the circumstances under which this treatment is covered. I imagine this is as close to being "in the handbook" as you can get. My husband's condition is listed there in black and white. We have a letter from the treating physician explaining all of this.
The hospital, however, never got a letter from the treating physician for the appeal, as far as I know. The fact is, I never got any notification of an appeal whatsoever.
Can you explain how this information regarding pre-approval is relevant to our current circumstances? I really don't think that pre-approval was applicable or required for this, as far as our insurance policy goes.
Answer
If the only problem is that the hospital billed it incorrectly, then all they should have to do is correct the bill and resubmit it. They don't need to appeal the denial. And if you are worried about it getting denied for not being filed within the time limit, because the original bill was submitted within the time limit, then they have met the timely filing requirements. Does the hospital agree that the original bill was incorrect?
If I am misunderstanding the situation, let me know. It sounds like this is a procedure that was already done, and the bill was denied, not that you requested authorization before having it done and THAT was denied.
Answer
I suggest having the insurance policy and declarations reviewed by an attorney who specializes in insurance law. There should be a section of the policy that deals with appeals and the right to have the appeal reviewed by a 'third party' instead of a review by the same people who made the initial denial of benefits. If the insurance company did not have the appeal determination made by someone who did not make the initial determination, there may be a way to gain another review of the appeal.
Unfortunately, there is the very real possibility that by failing to file the initial appeal and failing to keep up with the time limits, the policy holder has no recourse.
EC
Answer
There was an initial appeal to the insurance company, and that was denied. The issue is that we were not informed about the denial. Had we known, we would have had 45 days to file an external appeal with NY state.
Today I called the NY Insurance board and they told me that if the insurer did not inform us of the denial, then we can still file an appeal with them, explaining the situation. This was good news!
Further, I am pursuing things with the hospital. I left a message with the treating physician's assistant to call me, regarding having the procedure code changed to reflect the procedure that was performed, as described by the doctor in his letter on our behalf.
I think this would rectify things most rapidly, b/c then it would simply be submitted as a correction by the hospital.
Answer
I think this would rectify things most rapidly, b/c then it would simply be submitted as a correction by the hospital.
Exactly, no appeal is needed if it was a billing error. They only need to appeal if they are saying that the original code is correct as it was submitted, and they don't want to change it.
Answer
If you are still getting the run around, you should call the NYS Attorney General's office, 800.771.7755 extension 3. This department was created for problems like yours. What ends up happening is that you submit your claim/appeal, CC AG' s office, and then the AG's office then submits the CC to the HMOs legal department with an AG cover letter.
I just skimmed the above, but to skirt around the "experimental" issue, at least with my hmo, you'll need to provide two published studies, recommending the procedure. Make sure that you get your HMOs guidelines as to what is required to get approved for the procedure.
As others have mentioned, if you miss the appeals window, you can submit another claim.
Also, you might look at your HMO's "balance billing" policy. I think, at least in NY, that the provider/hospital HAD to notify you that the hospital-appeal was lost. The hospital/provider has a contract with the HMO that they have to follow, so demand that your HMO put in writing that the hospital/provider had to notify you. By law, the HMO has to, upon request, put policies in writing. Then call back the hospital and let them know that this is their problem.
Good luck.
Answer
Thanks for the great ideas. Right now, we are trying to get the treating physician to change the billing code to reflect the correct procedure that was performed. If for some reason he can't/won't do that, I will definitely pursue these other avenues until I get the bill paid for. Thanks so much for all the helpful advice!