Ok Come on man this cant be reality??

[vic120]

Ok I am in a situation again, My son needed tests, and we got a preauthorization to go out of network because there was no in network in our area at all

Then I get a bill for 12K saying it was out of network, and I called the ins company and they tell me sorry the Hosp did not include the preauth when they submitted bill so they are denying it
in fact they are saying it does not matter if we got the pre auth it only matters the hosp did not submit it with the claim

and I called the hosp, and they say they are working on it to see if there is anything they can do

but insinuating if not we will have to pay them 12K

I am sorry how is this even legal, I just don't have 12 K right now

 

[vic120]

I am serious I am looking for feedback on the legalities here
Because if they come back and say sorry there is nothing we can do
You took the time to get a referral and preauthorization prior too and made sure you had all the ducks in a row

and even though it was US who did not submit it with the claim

You still owe us the 12K

I am sure there has to be legal recourse I have

Thre has to be there is no way I should be on the hook for this legally??

 

[LeeV]

Sorry for your situation and frustration. Something does not pass the smell test here. Just because a preauthorization was not submitted with a claim does not automatically make that claim an ineligible expense. This occurs often, but the carrier/administrator will reverse the adjudication once the preauthorization is submitted.

There could be other reasons for the declination, but I do not have the plan documents or any other information so I cannot determine with certainty. Some tests require preauthorization, some do not. What do your plan documents say about tests/preauthorization?

 

[vic120]

Sorry for your situation and frustration. Something does not pass the smell test here. Just because a preauthorization was not submitted with a claim does not automatically make that claim an ineligible expense. This occurs often, but the carrier/administrator will reverse the adjudication once the preauthorization is submitted.

There could be other reasons for the declination, but I do not have the plan documents or any other information so I cannot determine with certainty. Some tests require preauthorization, some do not. What do your plan documents say about tests/preauthorization?

Not sure what you mean reveres the injunction

However I will say we did get the ourselves My wife did it and was sure to do it

there was no where else to go that was actually in network near us in fact even they were an hour away

My wife did call the ins company and was told specifically the reason for the denial was spaficly because the provider submitted the claim without the authorization

We did an apeal and was delcined again and was verified was because the provider did not include the autherization with claim

Believe me I have had way too many issue I was not going to do this without being assured it would be covered

 

[LeeV]

Adjudication is the claim process. Sorry, but your reply is confusing to me.

1. Was a preauthorization submitted to the carrier/claim administrator?
2. If yes, who submitted it? Your most recent post states that your wife confirmed the original denial was due to the lack of preauthorization. It also states that upon appeal it was denied a 2nd time, again for lack of preauthorization.
3. It appears that you obtained the preauthorization, is that correct?
4. If you did receive the preauthorization, did you forward to the carrier/administrator?

 

[scagnt83]

They do it because they can. And no regulator does anything about it.

Im sorry to hear you are going through this. I hope your son gets better soon.

Tell them you have filed a complaint with the DOI. And are seeking legal representation. At the same time, send in the proper paperwork. See what happens.

Or..

Try sending it all yourself as a reimbursement. It will trigger a new claim, new number, new claims rep.

What carrier is it?

 

[scagnt83]

Adjudication is the claim process. Sorry, but your reply is confusing to me.

1. Was a preauthorization submitted to the carrier/claim administrator?
2. If yes, who submitted it? Your most recent post states that your wife confirmed the original denial was due to the lack of preauthorization. It also states that upon appeal it was denied a 2nd time, again for lack of preauthorization.
3. It appears that you obtained the preauthorization, is that correct?
4. If you did receive the preauthorization, did you forward to the carrier/administrator?

He is saying that the doctor did not submit the pre-autho with the claim they sent to the carrier. Now the carrier is denying it, despite fixing the mistake and sending both together.

 

[vic120]

Adjudication is the claim process. Sorry, but your reply is confusing to me.

1. Was a preauthorization submitted to the carrier/claim administrator?
2. If yes, who submitted it? Your most recent post states that your wife confirmed the original denial was due to the lack of preauthorization. It also states that upon appeal it was denied a 2nd time, again for lack of preauthorization.
3. It appears that you obtained the preauthorization, is that correct?
4. If you did receive the preauthorization, did you forward to the carrier/administrator?

1 No the Preauth was not submitted with the claim by the provider
That is the problem

WE (MY WIFE) did get the authorization our seves gave it to the provider and the provider did not include it when submitting the claim

this is WHY we are being told it was declined

2 No it was NOT sumited the provider was supposed to submit it to the carrier when submitting the claim they failed to do this

3 YES my WIFE obtained the preauthorization

4 My WIFE forwarded it to the provider for the service

 

[vic120]

They do it because they can. And no regulator does anything about it.

Im sorry to hear you are going through this. I hope your son gets better soon.

Tell them you have filed a complaint with the DOI. And are seeking legal representation. At the same time, send in the proper paperwork. See what happens.

Or..

Try sending it all yourself as a reimbursement. It will trigger a new claim, new number, new claims rep.

What carrier is it?

The provider is saying they are looking inot it and needs more time, so it might get fixed I am just trying to see what my legal recourse will be if they try and charge us 12K

We did do everything we were supposed to do

 

[goillini52]

1 No the Preauth was not submitted with the claim by the provider
That is the problem

WE (MY WIFE) did get the authorization our seves gave it to the provider and the provider did not include it when submitting the claim

this is WHY we are being told it was declined

2 No it was NOT sumited the provider was supposed to submit it to the carrier when submitting the claim they failed to do this

3 YES my WIFE obtained the preauthorization

4 My WIFE forwarded it to the provider for the service

If the provider wants to get paid.....they should file the claim properly. The provider needs to refile the claim including the PA.

Good luck.