Medical Billing Help!

[hofan41]

Hi All,
I have been a lurker in ATOT for quite some time here, and am seeking some advice.

About a year ago, I went to a doctor to have a few toe surgeries involving ingrown toenails performed. At the time he had told me that I was fully covered and I would only need to pay the $10 deductible.

Fast forward to now, I recently received copies of the insurance claims that were denied and a rather hefty bill from my doctor saying that he has no choice but to bill me for the procedures.

First of all, how should I resolve this situation? Is there anybody I can hire who can help me track down the documents and resolve this issue for me?

Is it possible that I could be legally obligated to pay even though the only reason I agreed to have procedures done was because the doctor told me they were covered by insurance? Something seems terribly wrong if it is, because at that point doctors could just charge whatever they wanted and bill patients for anything the insurance didn't cover.

Thanks!

 

[xSauronx]

a few surgeries for ingrown toenails? jesus h christ man.

after having one cost me $75 i started to handle it myself after 2 shots of rum and a hot shower.

and i dont know anything about the insurance stuff

 

[hofan41]

Yeah I didn't feel like dealing with those anymore, so I opted to have some nail matrix removed from both my big toes. Quite a painful procedure, but nothing the vicodine couldn't handle!

 

[George P Burdell]

Did you call your insurer and ask them why the fuck they denied this?

 

[OdiN]

They put you on vicodine for that?

I had one on my left toe that got all messed up after I stubbed it real bad. No pain meds, just had to soak it and all sorts of crap for like a month.

 

[hofan41]

I don't think removing pieces of nail matrix from your toe is in the same ballpark as stubbing your toe. The nail matrix is located right above your bone, and in order to remove it you have to cut straight down till you touch the bone.

 

[hofan41]

Originally posted by: George P Burdell
Did you call your insurer and ask them why the fuck they denied this?

Actually they had responded to my doc with a letter which he forwarded to me which had all this medical procedure mumbo jumbo. That is why I asked if there was some profession I could hire who specialized in reading this mumbo jumbo.

The point still stands where my doctor thinks the insurance is totally responsible but unfortunately has to bill me because they are still denying the charges.

When I call the insurance company they tell me this matter is between them and the doctor. Although it really isn't if I'm getting a bill!!!!!

 

[Mahaguru]

That is how it works. He probably had you sign a document which says that you are responsible for the complete amount.

 

[Sphexi]

Unfortunately, whether or not the doctor told you it was covered, it's up to you to check with insurance before hand to verify this. Unless you have something in writing saying you didn't have to pay him if your insurance failed to follow through, which I doubt. He probably was acting in good faith, and for whatever reason your insurance failed to pay him, maybe they wanted a second opinion on this type of operation, or maybe they think it's bunk, whatever.

I'm betting he legally has the right to sue you, and if your insurance company isn't giving you a straight story on why they denied it you may be out of luck. A lawyer who has experience in medical based practice may be a good idea, if it's that hefty of a sum.

 

[james1701]

Uh they have to tell you why they wont pay, you pay for their service. There is an appeal process most insurance companies have. File for one. If they don't pay, then you are obligated to pay. Most doctors will take payments. Docs don't work for free.

 

[Tiamat]

call your insurance company and ask about why the procedure was denied. Tell your doctor that you are working with your insurance company presently.

Expect the insurance company to give you the run around. You have to keep on them and keep asking questions.

It took me 3 weeks (called every single day for 2 hrs) to get my insurance company to pay my 50k$ hospital bill. This was a huge waste of my time at work. Thankfully my boss was very nice about it. Turns out they denied my claim because they failed to send me a release form to allow the hospital to let the insurance company see my medical record. At no time did they accept responsibility for their mistake. I had to specifically ask them to send me Form XXXX so that I could fill it out and fax it to the hospital. In order for me to know which Form I needed, a nice person at the hospital explained the typical billing procedure.

Your situation is probably different, nevertheless, you need to get to the bottom of this immediately and keep your doctor in the loop.

 

[sixone]

Originally posted by: Sphexi
Unfortunately, whether or not the doctor told you it was covered, it's up to you to check with insurance before hand to verify this. Unless you have something in writing saying you didn't have to pay him if your insurance failed to follow through, which I doubt. He probably was acting in good faith, and for whatever reason your insurance failed to pay him, maybe they wanted a second opinion on this type of operation, or maybe they think it's bunk, whatever.

I'm betting he legally has the right to sue you, and if your insurance company isn't giving you a straight story on why they denied it you may be out of luck. A lawyer who has experience in medical based practice may be a good idea, if it's that hefty of a sum.

Yup, this is how it works.

If you have employer-provided health insurance, get your HR person to call the insurance company to request an explanation for the denial.

Otherwise, you'll need to find a lawyer who specializes in insurance claims.

 

[OdiN]

Originally posted by: hofan41
I don't think removing pieces of nail matrix from your toe is in the same ballpark as stubbing your toe. The nail matrix is located right above your bone, and in order to remove it you have to cut straight down till you touch the bone.

No they removed some on mine too. But they didn't cut to bone. They used acid.

 

[IHateMyJob2004]

I used to have cronic in grown to nails. Insurance always paid to resolve the issue and they did in fact pay to "burn" the root so the problem would go away.

 

[CrazyLazy]

I just woke up after fainting from reading the details in this thread.

 

[nanette1985]

Very possible that the doc's office used the wrong billing code. Call the insurance co to get the details of the denial, call the doc's office for explanations. Talk to HR or your insurance agent.

Spend a lot of time talking to the doc's office and don't let them send it to collection - that makes it a zillion times harder to get it to go away.

And keep records of everything that is said. Good luck!

 

[PClark99]

Could it be your insurance may also have a deductible which is an amount you need to reach before benefits kick in.

Ie. if your deductible is $500 and the surgery was $499, guess what, you owe $499.

 

[hofan41]

thanks for the advice, folks. i guess i will just have a headache to deal with for the next few weeks. argh.

 

[SirStev0]

Originally posted by: George P Burdell
Did you call your insurer and ask them why the fuck they denied this?

They'll just tell him to fuck off.

 

[hofan41]

Originally posted by: SirStev0

Originally posted by: George P Burdell
Did you call your insurer and ask them why the fuck they denied this?

They'll just tell him to fuck off.

hahaha, so true. I don't really understand a word the insurance people say to me. They keep telling me to check the explanation of benefits but those don't really explain anything either.

I thought they would keep this giant document on which procedures are allowed and covered and which are not based on your policy. Instead I get this small letter form listing the procedures that I had done, and whether or not they were allowed. Where do they get this reference material from to decide whether or not it was allowed?

 

[hofan41]

Originally posted by: CrazyLazy
I just woke up after fainting from reading the details in this thread.

On a side note, the nail matrix looks like a sliver of sashimi when it is removed from your toe.

 

[MikeyIs4Dcats]

you may appeal your insurance claim, but you need to call first and get the reasoning for denial documented.

and unfortunately your doctor has no say in if something is covered.

 

[james1701]

You probably needed to be preauthorized for the procedure and they are kicking it out because of this.