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this is part of what confuses me: if the insurance didn't cover those last days, why weren't we notified until after we had been discharged? Shouldn't the hospital have known what was approved? I'm thinking the case mgr at the hospital really dropped the ball.
The hospital is 'in network' and covered at 90%. Well at least the first couple weeks were.
He needs to make phone calls 1st. I posted the mock up letter because my windows computer just happened to be running; just in case he needs it.
Most hospitals won't give a crap. Depending on what doctor/hospital, the doctor may not have an office outside of the hospital & only see patients on the floor. My hub was in a trauma center where they did this.
The hospital should have called the insurance to get the authorization to keep her.
I might even put an order in for her records while admitted - the whole stay - including ER because it will show history.
Usually you don't have to file the appeal; the phone calls to the billing office, then the insurance company & maybe a time or 2 more; this all should be taken care of. Depending on the outcome of the phone calls to the hospital, I might go there in person to speak to a supervisor. If not, I would start getting everything ready to appeal.
What type of insurance do you have?
I am afraid that in this particular situation phone calls from OP to the insurer are just going to be very frustrating and add to his stress. He likely will be placed on hold, transferred from person to person and end up not having accomplished anything. He will not be able to tell the insurer what it wants to hear to justify the last seven days.
The admission itself is not being denied, just the last seven days.
I suspect that the hospital does "give a crap"; it wants to get paid. If the days are ultimately denied by the insurance company, and OP's wife was not informed that there was a possibility that those days would not be covered, it probably will violate the hospital's contract with the insurance company to bill OP's wife for those days. It is in the hospital's best interest to help get those days authorized. The hospital does what is called "utilization review" on a daily basis on inpatients. I suspect that OP's wife met the standard utilization criteria for continued admission. If so, the hospital would not have contacted the insurer to authorize additional days.
It does not matter if the physician is office based or hospital based. One physician, usually the doctor who did the original admission, is the "attending" for the case. Unless a formal transfer to another "attending" happens for some reason, that person is responsible for coordinating the care of the patient until she is discharged. This is the person who should do the appeal. OP's wife's attending was probably her surgeon. Whoever handles the surgeon's insurance claims should be able to help OP. Even if s/he is hospital based (and most surgeons are not), s/he will have a billing service that deals with insurance issues every day. It is possible that a letter from the attending fax'd to the insurance company would be all that is necessary. If that does not work, the attending may need to talk with the doctor that approves claims for the insurance company. The doctor to doctor route is most likely to be successful and in a shorter interval of time.
11thHour ~ Let your wife's doctor help with this. You concentrate on your wife.
this is part of what confuses me: if the insurance didn't cover those last days, why weren't we notified until after we had been discharged? Shouldn't the hospital have known what was approved? I'm thinking the case mgr at the hospital really dropped the ball.
The hospital is 'in network' and covered at 90%. Well at least the first couple weeks were.
See my response to Roselvr. The case manager may have been doing his or her job. There is the possibility that the insurance company was hoping you would just pay up --- that the appeal process would be so daunting that you would forgo it. There is also the possibility that they are just delaying and know they will ultimately have to pay, but behaviors like those will really get them in hot water with the insurance commissioner.
Again, I think you will find that, one way or another, you will not owe more than what you have already paid. If it comes to the worst case, ask the hospital to let you pay what the insurance company would have paid --- which is a greatly discounted amount. I do not think it will come to that, and I think you will find your doctor's office happy to help. They do not like insurance companies any more than you do!
Edited to add: your wife's doctor's insurance office may also have people they can contact directly at the insurer. They do not have to negotiate those awful telephone menus!
Last edited by suzy_q2010; 07-25-2010 at 06:03 PM..
In my professional opinion, it sounds like in this case unless your wife had a history of digestive diseases or conditions like Crone's or IBS or chronic indigestion where immediate attention would have been medically necessary, that it might have been a situation of the doctors and hospitals seeing an opportunity to turn what was probably a mole hill into a mountain to gouge her insurance and perfom the most expensive of procedures that might possibly be called for. Chances are she would have been fine just drinking some potassium broth and resting in the fetal position until the pain passed.
Although they should have enough experience with insurance companies to know that insurance doesn't pay claims unless they are medically necesary, Medical Doctors often fail to remember at the 11th hour that a claim might not be paid unless it is really necessary and go ahead and do the big unnecessary surgery anyway because it is an opportunity to make money. I wonder if in your wife's case all the surgeries were do to initially botched surgeries.
If I were you, I'd get an atty to go after the hospital and people that treated you or at least get a consultation from an atty with experience in this area.
Remember doctors and hospitals, especially in this country, are in business to make money. Often that means doing what is most elaborate and invasive and expensive rather than what is least invasive and least expensive and most effective. It sounds like, unless this was really a life or death situation, you were taken advantage of BIG TIME.
People have to WAKE UP and realize that Medical Doctors are just offering one alternative and it is usually the most invasive. Practitioners of Natural Medicine can help people with chronic conditions in a safer less invasive and less expensive manner that is FAR MORE EFFECTIVE than what practitioners of western medicine offer for the chronic diseases and conditions.
In my professional opinion, it sounds like in this case unless your wife had a history of digestive diseases or conditions like Crone's or IBS or chronic indigestion where immediate attention would have been medically necessary, that it might have been a situation of the doctors and hospitals seeing an opportunity to turn what was probably a mole hill into a mountain to gouge her insurance and perfom the most expensive of procedures that might possibly be called for. Chances are she would have been fine just drinking some potassium broth and resting in the fetal position until the pain passed.
Although they should have enough experience with insurance companies to know that insurance doesn't pay claims unless they are medically necesary, Medical Doctors often fail to remember at the 11th hour that a claim might not be paid unless it is really necessary and go ahead and do the big unnecessary surgery anyway because it is an opportunity to make money. I wonder if in your wife's case all the surgeries were do to initially botched surgeries.
If I were you, I'd get an atty to go after the hospital and people that treated you or at least get a consultation from an atty with experience in this area.
Remember doctors and hospitals, especially in this country, are in business to make money. Often that means doing what is most elaborate and invasive and expensive rather than what is least invasive and least expensive and most effective. It sounds like, unless this was really a life or death situation, you were taken advantage of BIG TIME.
People have to WAKE UP and realize that Medical Doctors are just offering one alternative and it is usually the most invasive. Practitioners of Natural Medicine can help people with chronic conditions in a safer less invasive and less expensive manner that is FAR MORE EFFECTIVE than what practitioners of western medicine offer for the chronic diseases and conditions.
I am awfully glad that Mrs. OP did not ask for your "professional opinion." Let's see, according to your CD public profile, you sell insurance. That makes you much more qualified to provide advice than a "practitioner of western medicine", right?
If she had drunk your "potassium broth" and "rested in the fetal position", the pain would have "passed" all right. So would Mrs. OP. The condition she had was lethal if not treated.
By the way, it's Crohn's, not "Crone's".
Last edited by suzy_q2010; 07-25-2010 at 06:20 PM..
Reason: correct typo
In my professional opinion, it sounds like in this case unless your wife had a history of digestive diseases or conditions like Crone's or IBS or chronic indigestion where immediate attention would have been medically necessary, that it might have been a situation of the doctors and hospitals seeing an opportunity to turn what was probably a mole hill into a mountain to gouge her insurance and perfom the most expensive of procedures that might possibly be called for. Chances are she would have been fine just drinking some potassium broth and resting in the fetal position until the pain passed.
Although they should have enough experience with insurance companies to know that insurance doesn't pay claims unless they are medically necesary, Medical Doctors often fail to remember at the 11th hour that a claim might not be paid unless it is really necessary and go ahead and do the big unnecessary surgery anyway because it is an opportunity to make money. I wonder if in your wife's case all the surgeries were do to initially botched surgeries.
If I were you, I'd get an atty to go after the hospital and people that treated you or at least get a consultation from an atty with experience in this area.
Remember doctors and hospitals, especially in this country, are in business to make money. Often that means doing what is most elaborate and invasive and expensive rather than what is least invasive and least expensive and most effective. It sounds like, unless this was really a life or death situation, you were taken advantage of BIG TIME.
People have to WAKE UP and realize that Medical Doctors are just offering one alternative and it is usually the most invasive. Practitioners of Natural Medicine can help people with chronic conditions in a safer less invasive and less expensive manner that is FAR MORE EFFECTIVE than what practitioners of western medicine offer for the chronic diseases and conditions.
Her bowel had a rupture. She had muliple abcesses in her abdomen. She was very septic and she had a raging fever. Ie, she was dying. The medical care she received was actually fantastic and I have nothing but good to say about her docs and nurses, afterall they saved her life. They were all great. It's the insurance that is jerking us around.
Sir I will give you the straight skinny on this thing. I'm with emily but it's the med record charting that caused the denial IMO.
You need to get a lawyer and sue the hospital for substandard documentation in your wife's medical chart which resulted in your insurance company not able to find justification for the stay resulting in a denial (or something like that). The insurance company will not pay for "no" services rendered. It is the job of the doctors and nurses (in particular) to chart accordingly so the hospital will get paid.
I train nurses how to chart for a living. Hospitals and health care companies bring in types like myself constantly to update and check records, do in services to the nurses because hospitals are loosing their shirts because nurses aren't charting correctly. If the nurse charts the patient is doing fine everyday then the insurance company will not pay. There must be detailed progress notes by the nursing staff every shift to justify the patients stay.
Slow down, take a breath and figure out who you really need to go after to pay for this. IMO it's the hospital because the health insurance companies have very clear standards with regard for payment and these nurses and doctors know this. It sounds like someone got very sloppy.
Get all the medical records and an attorney. That means the nurses progress notes because that's where the insurance companies look for justification for payment.
If the records show that no care was given when in fact your wife was having procedures done, an IV, blood pressures/vital signs done every shift, medications, Dx, plan of care shift to shift, RN assessments, Dx, implementation of care, infection control measures, measurable outcomes and outcome etc...I mean I could go on forever but I think you get my point; it needs to be clearly charted in the medical recored every shift every procedure every bit of care.
Get the medical records (your wife signs a medical release and they must turn over copies to her/you). They will charge for the copies. But be clear you want the nurses progress notes and any other assessments from any doctor or social worker, labs, MDS, test results all of it. They will tell you that it's a lot of paper trying to discourage you but for that length of stay there should be at least 100 pages if not more. If you find it's all documented accordingly then you can go after the insurance company but somehow I don't think it will be the case.
Sir I will give you the straight skinny on this thing. I'm with emily but it's the med record charting that caused the denial IMO.
You need to get a lawyer and sue the hospital for substandard documentation in your wife's medical chart which resulted in your insurance company not able to find justification for the stay resulting in a denial (or something like that). The insurance company will not pay for "no" services rendered. It is the job of the doctors and nurses (in particular) to chart accordingly so the hospital will get paid.
I train nurses how to chart for a living. Hospitals and health care companies bring in types like myself constantly to update and check records, do in services to the nurses because hospitals are loosing their shirts because nurses aren't charting correctly. If the nurse charts the patient is doing fine everyday then the insurance company will not pay. There must be detailed progress notes by the nursing staff every shift to justify the patients stay.
Slow down, take a breath and figure out who you really need to go after to pay for this. IMO it's the hospital because the health insurance companies have very clear standards with regard for payment and these nurses and doctors know this. It sounds like someone got very sloppy.
Get all the medical records and an attorney. That means the nurses progress notes because that's where the insurance companies look for justification for payment.
If the records show that no care was given when in fact your wife was having procedures done, an IV, blood pressures/vital signs done every shift, medications, Dx, plan of care shift to shift, RN assessments, Dx, implementation of care, infection control measures, measurable outcomes and outcome etc...I mean I could go on forever but I think you get my point; it needs to be clearly charted in the medical recored every shift every procedure every bit of care.
Get the medical records (your wife signs a medical release and they must turn over copies to her/you). They will charge for the copies. But be clear you want the nurses progress notes and any other assessments from any doctor or social worker, labs, MDS, test results all of it. They will tell you that it's a lot of paper trying to discourage you but for that length of stay there should be at least 100 pages if not more. If you find it's all documented accordingly then you can go after the insurance company but somehow I don't think it will be the case.
Good luck sir
Yes, documentation is necessary, but OP mentioned there being a case manager. That would be someone checking the chart on a daily basis to make sure all the i's were dotted and t's crossed. To get an attorney involved at this point would be very premature. The insurer's appeal process has not been followed yet, and you agree to that by purchasing a policy. No attorney is likely to take this on a contingency basis, and the lawyer's fees would be as much as the hospital bill. I've said this several times, but I'll repeat it: if the insurer denies those days, it is probable that the hospital will have to write it off because they did not tell Mrs. OP that the days might not be covered. More than likely, Mrs. OP's doctor will be able to get those days approved. Our goal here is to help OP do things in the least stressful way. That does not mean starting lawsuits.
Don't sweat it yet. I have had to help many clients with insurance appeals. The most important thing to remember is to follow the instructions they give you, and always always always submit by the deadline they give you. Keep a copy of everything they send you, and a copy of everything you submit.
Yes, documentation is necessary, but OP mentioned there being a case manager. That would be someone checking the chart on a daily basis to make sure all the i's were dotted and t's crossed. To get an attorney involved at this point would be very premature. The insurer's appeal process has not been followed yet, and you agree to that by purchasing a policy. No attorney is likely to take this on a contingency basis, and the lawyer's fees would be as much as the hospital bill. I've said this several times, but I'll repeat it: if the insurer denies those days, it is probable that the hospital will have to write it off because they did not tell Mrs. OP that the days might not be covered. More than likely, Mrs. OP's doctor will be able to get those days approved. Our goal here is to help OP do things in the least stressful way. That does not mean starting lawsuits.
I would bet quite a bit to venture that just because there's a "case manager" required charting got done. Of course there's a case manager, they're part of the team and many of them don't have a clue either.
I agree not to get an attorney right away. I would get the chart as I suggested and see for myself because that is the only reason the insurance company denied the claim. Let me say that again; the only reason it was denied is due to inferior charting or charting that could not back up a claim for payment.
Unless I'm mistaken; what other reason would an insurance company give to deny claims such as these?
Like I said; somebody got very sloppy and if he get's the chart and plays his cards right he won't have to pay a dime. In fact if the hospital is aware that he's following up in this manner they may forgo all claim who knows but he needs to put the action of aquiring the chart into play IMO.
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