I am writing for comments and ideas on handling my current problem. About a year and a half ago, I went to a new doctor whose practice concentrated on proper nutrition and vitamin supplementation, among other things, for good health. Even though she was an MD, knowing that her practice was a little different than most, when she recommended that I have a particular screening test because of high blood pressure, I immediately asked her if my insurance would cover it, and they indicated it would. When I went to the facility that gave the test, I also asked them if it would be covered by my insurance, and they also indicated it would be. In the meantime when the report for the test came back, it made me appear to be a walking time bomb about to have a heart attack. The doctor recommended that I see a cardiologist who said the only way to know now if there was a serious problem was to have an angiogram, which I did. After the angiogram, the cardiologist told me I was fine. After many phone calls and correspondence between the facility requesting payment, my insurance provider, me, and the doctor, my insurance provider claimed the test was investigational/unproven or not medically necessary. Now I am stuck with a $2600 bill which has been turned over to a collection agency, and they are beginning the calls. I had pleaded my case to the facility requesting payment, but to no avail. I do not feel liable based on my being misled and sent for a test under false pretense--and particularly an investigational test that I was not even informed of.
Generally you are liable for all the medical care you are given even if you have insurance and the insurance refuses to pay. This is a common problem in the US today because people often seem to be unclear about this.
I would also recommend to contact the state medical comission or a lawyer to check out all the options you have to fight this. It justs tell us that most doctors and employees at medical institutions don't know anything about insurance coverage. You have to be really careful and should check it yourself, don't trust people that won't have to pay the costs.
Oh, believe me, I will check any procedure I get in the future with my insurance company. This would be an expensive lesson for me, but I also question was I the first person that doctor sent for that investigational test. It is hard for me to believe that others didn't have the same problem, or are there a lot of people out there who knowingly would take a test that's not covered by insurance and pay $2600 outright. And as I said before, to boot, the test proved to be highly inaccurate.
So, essentially, the people who claimed that it was covered by insurance are the people who are billing you for it.
Yes, correct, but first I asked the doctor who prescribed the test if my insurance would cover it. Her office said yes. Then when I went to the particular facility for the test, I asked again, and they indicated it would.
More importantly, what does the contract that the OP signed with the doctor say? Does it say that the OP is responsible for all costs no matter what? In court, won't the creditor claim that the parol evidence rule precludes adding in the lies that the used car salesman told you to get you to buy the car because those lies are directly contradictory to the fully integrated written contract you signed that plainly says "AS IS"?
I didn't realize preauthorization was required, but also if anyone had mentioned that it was an unproven test, that would have been an alert to me to check further or not take the test at all and to seek some other alternative.
Follow the normal appeals procedure for your insurance company. I had a similar situation in which my medical insurance denied payment. I appealed, they said there medical doctor said it was not medically necessary. I asked if that doctor was licensed in my state, the test was approved and paid for.
I appealed it once with my insurance company, but the doctor who had my appeal upheld the original denial. The administrator of our insurance plan also told me it was up to me to check with the insurance company for coverage of the test.
The doctor that upheld the insurance denial, is he or she LICENSED in your state? If not that is malpractice.
Unfortunately, most people rely on their health care provider to know the ins and outs of their coverage and a medical office will call to verify insurance (a good medical facility). The answer they get is that in most cases is a disclaimer stating that the answer they give is not a gaurantee of coverage and until the claim is processed a determination will be made. The best thing a consumer to do is ask the medical office what procedure codes they are going to bill under and themselves call the insurance company, get a name and ID number if possible with an explanation if the benefits will be covered or not. We have a screwed up system dealing with insurance and in any court, imho it is up to the consumer to know exactly what their coverage will provide. More work as a consumer I know but this will give you legal standing if this situation goes to collections or court.
