post op insurance question

[Guest guest]

Hi Guys...

I had my upper and lower surgery pre-approved by my insurance

company - Humana - and my surgery was a great success!!!

However, I just recieved word that there are two very large charges

that my hospital billed to Humana, that Humana has declined -

or " excluded " as they term it - due to the charge being larger than

the " allowable amount " . Therefore, I think I am to be held

responsible for the charge. I just spoke with someone at the

insurance company - and they were absolutely no help....I may have to

appeal teh decision - or go to the hospital and have them re-submit

the claim....I don't know!!!

Has anyone ever experienced this exclusion and been successful in

fighting it?

Let me know...

I was in shock when I recieved the bill!!!!

-malu

[Guest guest]

Don't get worried too soon. It is a normal practice for hospitals

(or any health care providers) to bill more than what the contracted

rate with the insurance company is, for business and tax purposes.

The rate that is agreed upon by the hospital and the insurance

company is usually less than the hospital charge (insurance company

gets a price break by supplying the patients to the provider. This

also helps explain why a self-pay person pays more than the

insurance company). I don't know if you have an indemnity plan, a

PPO or an HMO, but most likely you don't have to pay anything. In

fact, if you have HMO coverage, the provider is legally prohibited

from balance billing you (don't know if this law is state-specific,

or Federal, but works for NYS). Another thing that might be helpful

is to read carefully about your benefits, and if the providers might

be balance billing you.

Irene.

> Hi Guys...

> I had my upper and lower surgery pre-approved by my insurance

> company - Humana - and my surgery was a great success!!!

> However, I just recieved word that there are two very large

charges

> that my hospital billed to Humana, that Humana has declined -

> or " excluded " as they term it - due to the charge being larger

than

> the " allowable amount " . Therefore, I think I am to be held

> responsible for the charge. I just spoke with someone at the

> insurance company - and they were absolutely no help....I may have

to

> appeal teh decision - or go to the hospital and have them re-

submit

> the claim....I don't know!!!

> Has anyone ever experienced this exclusion and been successful in

> fighting it?

>

> Let me know...

>

> I was in shock when I recieved the bill!!!!

>

> -malu

[Guest guest]

I don't know whether this relates at all. But on most medical

procedures we have, the doctor submits a claim that's higher than

the " usual and customary fee, " or what the insurance company says

is " usual and customary. " Because our docs are all preferred care

providers, the docs then write off the difference, as they agreed

with Bc/Bs to do when they became preferred providers.

I'd guess that if your hospital has no such agreement with Humana,

you probably don't have any leverage about it, but it's worth finding

someone who does know and can help you figure it out and/or fight it.

I think I'd start with my surgeon's office. Ask to speak with the

person who handles insurance there, and begin by saying that you

don't understand why there's this fee that you weren't expecting.

They may be able to resolve it for you easily. If so, I'd be sure to

remember to mention it to the surgeon at my next appointment and be

appropriately grateful. If not, I'd be even surer to mention it to my

surgeon at my next appointment, and be upset and worried about why

he's leaving you with this bombshell!

Best,

Cammie

> Hi Guys...

> I had my upper and lower surgery pre-approved by my insurance

> company - Humana - and my surgery was a great success!!!

> However, I just recieved word that there are two very large charges

> that my hospital billed to Humana, that Humana has declined -

> or " excluded " as they term it - due to the charge being larger than

> the " allowable amount " . Therefore, I think I am to be held

> responsible for the charge. I just spoke with someone at the

> insurance company - and they were absolutely no help....I may have

to

> appeal teh decision - or go to the hospital and have them re-submit

> the claim....I don't know!!!

> Has anyone ever experienced this exclusion and been successful in

> fighting it?

>

> Let me know...

>

> I was in shock when I recieved the bill!!!!

>

> -malu