Health Insurance Questions

[schwarz633]

Looking for some advice from the PPOT collective wisdom.

In Sept. 2020 my wife had a trip and fall incident that required rotator cuff surgery. I was working at that time and had medical coverage from UHC. Most of the services were submitted to UHC before the end of the year. Once the deductible was met UHC paid at 80%. She was prescribed a fancy CPM (Continuous Progressive Motion) chair and heavy duty sling device, but I have never seen a bill from this provider, only a few UHC documents indicating that a claim had been submitted and rejected due to incorrect coding.

A few days ago I received an EOB (Explanation Of Benefits) document from UHC indicating that the CPM chair wasn't covered for rotator cuff surgery ($4330 for 35 days). It also indicated that the sling was covered ($1210 billed, $426 allowed). The $426 was applied to my deductible which I thought was in error, but a conversation with UHC today has revealed that the deductible is applied at the time the claim is settled, not the date of service. This surprised me, if it would have been billed before the end of the year when my deductible was satisfied UHC would have paid at 80%.

UHC is telling me that the medical equipment provider did apply for a pre-approval from UHC and was told that only the sling was covered not the CPM chair. Shouldn't someone have informed me of that prior to delivery of the CPM chair?

I fully expect to be getting a bill for $4750 in the near future, just not sure how to handle that. I feel the provider should take some liability for their inability to file a valid claim in a timely fashion, as well as not informing me that the CPM chair wasn't going to be covered by UHC.

I'm currently retired, collecting SS, and on Medicare. Should I just tell them to pound salt, or offer up some token amount to settle? I can't think of any scenario going forward where I really care about my credit rating.

[Crowbob]

If you can find some kind of document that demonstrates that you asked if X is covered and if it isn’t you don’t want it but they provided it anyway, it might give you weight to dispute the claim.

Also, the amount owed can sometimes be negotiated or go to arbitration.

[wilnj]

As a last resort, can you set up an HSA? That allows you to use pre tax income for payment at the time payment is made, regardless of the date of service.

If you can negotiate the cost down it may be of additional help.


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[MBAtarga]

I just got a debt collections notice for a biopsy (well - actually 3 come to find out) from a provider in Tennessee that I've never heard of. I called them up for more info - they claimed they sent me bills - and this was for an endoscopy I had in January 2021! Two years ago! I told them to cancel the debt collector, send me a bill - and then I'll consider paying it. It's not really the money - just under $250 - but the principle of the thing.

I'd call up the provider and work out a discount and a payment plan that you think is reasonable. Certainly argue you should have been told the chair was not covered by insurance and let you decide if you wanted it. I wouldn't offer more than 10% for sure.

[A930Rocket]

Originally Posted by MBAtarga

I just got a debt collections notice for a biopsy (well - actually 3 come to find out) from a provider in Tennessee that I've never heard of. I called them up for more info - they claimed they sent me bills - and this was for an endoscopy I had in January 2021! Two years ago! I told them to cancel the debt collector, send me a bill - and then I'll consider paying it. It's not really the money - just under $250 - but the principle of the thing.

I'd call up the provider and work out a discount and a payment plan that you think is reasonable. Certainly argue you should have been told the chair was not covered by insurance and let you decide if you wanted it. I wouldn't offer more than 10% for sure.

I had something similar for about $50 with medical billing and went to a debt collector. I did not even know about it until they started calling me. It took years to get resolved and was on my credit report until then.

Sorry I don’t have any good advice for you 633.

Debt collectors are the scum of the earth.

[LWJ]

The answers will ALL reside with the agent that sold your (former) employer this policy.

So, I currently make my living selling group health insurance and P/C to businesses. This is bread and butter stuff for me. I have staff that answer these questions all day long. Their job is to advocate for you to the insurance co. Don't think that an EOB is the final word. It isn't. Call the rep. and talk.

Here is what I would do:

1. Call the rep. Find out what the protocol on pre-authorization is. Where is your responsibility to even KNOW about this?
2. Find out about the time vs the deductible as it applies to the sling and the chair. This, too, seems suspect.
3. If UHC is being shady - file a complaint with the State Insurance Division. This will get lots of people's attention. You can add the agent to the complaint as well even if they are doing a great job. It will make folks run around like a bunch of ants on fire. Watch!
4. If it is a mis-understanding, sit back and enjoy.
5. If at the end of the day you legitimately owe for things, play the "I'm retired and broke" card. My buddy had a heart attack a while back and the hospital wrote off all but a couple hundred dollars of a multiple day stay. SIMPLY BECAUSE HE ASKED. If not, they would have collected on this bill.

Good luck. Report back. Health insurance is absolutely broken. Sometimes, you need to smack the carrier hard and get their attention.

Don't forget, I'm a professional.

[Tobra]

I would encourage you to contact the state insurance commissioner in whichever state this happened.

Originally Posted by schwarz633

The $426 was applied to my deductible which I thought was in error, but a conversation with UHC today has revealed that the deductible is applied at the time the claim is settled, not the date of service. This surprised me, if it would have been billed before the end of the year when my deductible was satisfied UHC would have paid at 80%.

I am fairly certain this is wrong. I talked to my office manager who does the billing. This is the sort of thing that can vary from state to state though, but I am pretty sure everything goes by date of service. They check to see if the policy is in force on the date of service, not on the date they write the check. I can see how doing it that way would be WAY better for the insurance company, so maybe they had their lobbyist tell the legislature what to write in the law.

Originally Posted by schwarz633

UHC is telling me that the medical equipment provider did apply for a pre-approval from UHC and was told that only the sling was covered not the CPM chair. Shouldn't someone have informed me of that prior to delivery of the CPM chair?

Yes, they are supposed to inform you of this. Shenanigans on the part of the DME provider, UHC or both.

[DonDavis]

Originally Posted by LWJ

…snip…Don't forget, I'm a professional.

What LWJ said, x2

Your employer has an advocate on your behalf. Contact HR and ask them.

I’m going through some coverage challenges with UHC right now. I’ll know more in a couple weeks.

And LWJ is spot on, yo.

[cstreit]

One takeaway here is before ANY planned procedure ask them in writing to inform you of any procedure they may recommend in that facility or as a result is not covered by your insurance.

I read a story of a person who got stuck with a 6 figure bill for a basic procedure because one aspect of it was outsourced to a 3rd party who operated inside the hospital and they didnt know.