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Insurance co. won't finish payment

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jb:
Hi all, I'm having a hard time getting my insurance company to finish paying for my treatment and I'm not quite sure what to do.  I had an out-of-state claim, but apparently it was misprocessed as an out-of-network claim and only paid at 50%, even though my procedure was pre-approved at 100%.  The insurance reps I've spoken to on the phone (multiple times) have all agreed it's a mistake on their end, and assure me that my claim is 'prioritized' for reprocessing.  This has been going on for 3 months and nothing is getting done.  In the meantime, I'm left having to pay $1,500/month to the hospital on my remaining balance due.  I expect to be reimbursed eventually, but am beginning to wonder??  ???

I'm about ready to call the local TV 'action guy', but I was just wondering if anyone had a similar experience and how they resolved it.  Are there any insurance 'watchdogs' I can complain to?

OMG16:
JB I'm sorry to hear that you are having problems.  Is the hospital helping you with this?  If not call the insurance back and request to talk to a supervisor.  When you have them on the line get the name of the person you are talking to and their phone number and extension.  Ask them to give you their fax Number and fax a copy of the letter along with an appeal letter.  You only have a short period of time to do this so sending an appeal letter now is a good idea and can prevent problems down the road.  Ask them when they plan on making the additional payment and remind them nicely that it was a clean claim and everything was pre approved and that it should have been processed 30 days from the date they received it.  Since it has been so long and is costing you money that you do not have ask them nicely to process it now.  Then ask when you should expect payment to go out.  Let the hospital know all you are doing and ask if they can suspend the requirement that you have to pay the balance until it is all settled.  If that does not work call the news and give it over to them.  I have seen in our area this has been effective.  Good luck it is a nightmare.  16

sgerrard:
I would get a phone number and fax number for the hospital, and the same for the insurance company. Be sure to contact the doctors involved with your procedure directly, so they know what is happening. They will refer you to their assistants, who should be able to help organize things. Get the assitants' phone numbers and fax numbers. At the insurance company, try to get in touch with the nurse practitioner or some one who can make decisions directly. Then get these two groups talking and faxing directly to each other.

Ask for copies of all medical reports, etc. from the hospital, and make sure the insurance company has all of them. Then fax them another full set just for good measure. Get copies of all billing records you have so far - and fax everyone extra copies of those as well. If someone says it will be reprocessed, be sure to write down their name and their statement - and fax it. If you paid something to the hospital, make copies of those statements and payments, and a note that you expect reimbursement. Fax everyone copies of those as well.

Your case needs to land in the in box on both ends every day until it is cleared up, with all pertinent information readily at hand, no setting it aside while they look things up. I found that having copies of everything, and faxing them to both ends, and getting people talking to each other, made all the difference in getting the billing process straightened out and working smoothly. Call both ends, and fax everything again if they are not already holding it in their hands as you speak. Communication is key.

Hope it happens soon. Steve

Don:
 Dealing with these people is always a drama as I mentioned I am blessed as the choices I made early in life left me with 4 health care options for the rest of my days I am presently covered by a Federal Blue Cross plan, Military Tri Care and the VA and Medicare A&B and they still try to bill me? I had to go back to using the VA once I got my SSDI and Medicare as Medicare becomes your primary and they refuse or are unable to coordinate benefits and dont pay for most things? Anybody who thinks government health care is the answer stand by its all done with smoke and mirrors, my premiums are paid by my annuities and retirements but the system leaves a lot to be desired I paid out of pocket for my tumor removal not knowing my Blue cross was still valid as I was not yet on SSDI/ Medicare and it took about 3 months to get my money back I came home on a Thursday, the bill showed up Friday they had their check on Monday but me I gotta wait 3 months? Be firm go to the TV action line as healthy folks have no idea of the scams I used to respect the medical professions till I died and now know better be fair but firm never give an inch your life depends on it. I may be brain damaged but Im not stupid.............

jb:
Thanks for the advice.  You guys are right, I'm just going to have to dig in with these people and get things in writing until this gets settled.  I thought the hard part would be getting the insurance co. to acknowledge their mistake.  Still hard for me to believe they admit the mistake (at least on the phone), but don't do anything about it for over 3 months.  >:(

The hospital billing people have actually been pretty nice, but reminded me it's ultimately my responsibility, so I went ahead and started paying on it.  They said I'd get reimbursed when they get the insurance money, so hopefully it'll turn out that way.  We'll see....

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