Dealing with Insurance Coverage

[ks1490]

Following on from the earlier thread about how much people's surgery cost, I wanted to get a sense of the best way to clear the surgery in advance with one's insurance company. Did you contact the insurer directly to ensure that you were covered? Did the doctor handle the advance paperwork to ensure that you were covered? I'm interested in what people's experiences have been. Thanks.

 

[geebee]

I didn't do anything in advance. I had so many problems before each of my surgeries that insurance coverage just didn't factor in.

 

[Ross]

Same as Gina, not a thing!

 

[mtkayak]

Fortunately, I had time before my surgery to make some phone calls before surgery but they were probably not needed. I called my insurance to make sure the hospital and the surgeon were "in network" and they were. I did this because I had surgery out of state. That's all I really did. I knew what my deductible and "out of pocket" expenses so I knew how much I would be repsonsible for. If you have your medical records transferred to another hopsital they usually transfer all your insurance information as well. They ALWAYS check your insurance information. They want to make sure they get paid , healthcare is a business as well

I've called my insurance too for Post Op care (cardiac rehab and Protime home kit ) as well and they usually ask for a procedural code. The hospital usually handles all this too because they give the procedural code to the insurance company to see if it's covered.

 

[mntbiker]

I contacted my insurance company to find out what they would need in advance. I was told that for something as serious as heart surgery the doctors office would need to contact them since they would need specific information regarding the procedure.

Short term disability however has been a royal pain with all the forms they require in advance.

 

[Lynlw]

when ever Justin had surgery that we knew about before hand (2 out of the 4) the doctors/hospitals made all the arrangements w/ insurance BUT I always make sure to call and double check and find out if i will owe anything and make sure to get the person's name and write it all down. we've had a few battles over the years and 3 of his surgeries were in different states than we lived in (well beside the 4ohs, the broken pacemaker removal, he also had pyloric stenosis surgery and 2 surgeries when he broke his arm to put rods in and take rods out) so actually 6 of of his 8 surgeries were done out of state so I double and sometimes triple check, just to play it safe. Lyn

 

[PamO]

Insurance companies have a new loophole to get out of paying claims - that they weren't "pre-authorized." They can disallow up to 50% of what would be covered, which leaves you responsible.

Most procedures need to be pre-cert before the provider will schedule it. But, check, check, check yourself the day before you go in for anything, an x-ray, MRI, CATScan, angio, EKG, colonscopy, etc., and make sure that your doctor, surgeon, etc., has covered all of the bases with the insurance company. This way, YOU are sure that everything is hunky-dory with the insurance company and not relying on the doctor/surgeon's nurse saying, "oh yes, we did that." Maybe they didn't or didn't see it through to completion. It happens.

Being proactive about your coverage now goes hand in hand with being proactive about your health. They're one in the same.

 

[RandyL]

I let the surgeon and the hospital handle all the insurance. All I did was give them my insurance info and they did the rest. The way I figured it they will make sure it is covered and they are going to get paid before the procedure.

 

[OldManEmu]

Get it in writing

Get it in writing

While not having any direct experience with the US medical insurance system, I can only say when dealing with insurance in general "get it in writing". If you see any possibilities that they may not pay for something ask in writing first and demand a written response. They take the premiums in the good times and try to avoid paying in the bad times. Insurance companies like to worm out of anything they can.

 

[Janea]

My Cardiologist submitted a referral to the surgeon and I got a letter from Group Health that it had been approved (meaning Group Health would cover it. I then called Group Health just to make sure what my co-pay would be (nothing). Hooray for me!

 

[Marguerite53]

DEFINITELY what Mike and David and Pam said!!! PLEASE get on the phone and call your insurance people to be certain that there is nothing you need to do on your end of things. Everyone's insurance is so different. Many require pre-authorization. They want to hear from you (since it is elective surgery) that is is something you are electing to do and that your team of doctors does in fact see it as necessary. Yes, my doctors were way ahead of me and filed all the necessary papers (this is a big one -- they want to be paid) but when I called the insurance company she was REALLY GLAD I called since it was necessary for her to hear from me in advance. And then, her remark, "people always get so mad at me afterwards because we can't pay out at the same rate if we don't hear from them before....but it's all stated so clearly in their insurance brochure......they just choose not to read it"

Please call them!!

Marguerite