Insurance Fun and Games

I know it is a blessing that I have a good health insurance plan. I did not have to make any health care decisions based on financial worries. I can't even imagine the struggle of going through a cancer fight with no or inadequate insurance. So, while I am going to complain about my health insurance company, I know there are others out there wishing they had my insurance even with the headache of dealing with them.


So, back in July I was having quite a bit of back pain. One day while I was massaging it, I felt a lump just to the right of my back bone. The last time I found a lump, it did not go well. I wrote about the ensuing PET scan a few posts back. Fortunately, the results came back clean.

I received a claim report from my insurance company about a month later. It said that my PET scan was not covered by my insurance and that I was responsible for the entire $6,700. My breath caught in my throat but it had to be a mistake - right!? I pulled up my coverage plan online and right there it said that PET scans are covered at 90% after my deductible. I also noted that the coverage said that if I used a preferred provider, it was the provider's responsibility to make sure that the scan was pre-authorized. Excellent news.

I called my insurance company first. I talked to a nice lady named Carolyn. She looked up my claim and agreed that it was indeed covered under my insurance plan but that the radiology center did not have it pre-authorized. She said that they could at this point try to get it post-authorized. OK - strange that they did not get a pre-authorization but now I have a starting point to get this fixed.

I called the billing department of the radiology center. No, I was told they would not be the one's to have it pre-authorized, it would have been my doctor who would done it before even having the PET scan scheduled.

I called the financial lady at my oncologist's office. What?! They would never be the one's to get the pre-authorization, they would send my medical records over to the radiology center and it would be the radiology center who would call the insurance company. Great. The financial lady did give me a phone number for the supervisor of the department in radiology that gets pre-approvals.

I called the supervisor of the department in radiology that gets pre-approvals for PET scans. The supervisor was busy but I did talk to a helpful lady who was able to pull up my account. Here it is - the billing department should have been able to see this also - but we did call for a pre-approval and "Jeff" at your insurance company said it did not have to be pre-approved. The helpful lady said that she would call again and have it post-approved. She said that if I received a bill from them for the entire amount, I should call the radiology billing department again and they would put the bill on hold until this was all figured out.

Great - this seems to be taken care of. Two weeks later I received a bill from radiology for the entire amount.

I called the radiology billing department to put the bill on hold. Another nice lady looked up my account. They had tried to have the PET scan post-approved but my insurance company told them that the procedure was not covered under my plan. She could give me an extra two days to pay the bill but I need to start making payments in two weeks. And they will only give me 6 months to pay the bill so my first payment needs to be over $1,000. Wonderful.

I called my insurance company - and got Carolyn again. Her lucky day. She looked up my account. Yes, she can see where "J" (for "Jeff'?) told Vicki at the radiology department that the PET scan did NOT need to be pre-authorized. However, it did need to be pre-authorized. She did not at all see my frustration of the insurance company saying BEFORE the PET scan that it did not need to be pre-authorized and now saying AFTER the PET scan that it did need to be pre-authorized. Are you kidding me? But it gets better. So, she says that radiology will need to have it post-authorized. I understand, I say, they did try to have it post-authorized but when radiology called the insurance company, they were told that the procedure was not covered under my plan and the insurance company would not let them post-authorize it. Yes, Carolyn says, she can see where radiology called and was told that the procedure was not covered. The person at the insurance company, however, was "looking at a screen in the new system where it looks like PET scans are not covered but if they look at a screen in the old system it shows that it is covered" She suggested I call radiology back and that the person who calls this time to have it post-authorized should be persistent and ask for a supervisor. While Carolyn was always very friendly, she never did acknowledge that what she was telling me was just beyond frustrating. I thought about it later and working for this insurance company, she must spend 8 hours a day dealing with their ineptitude or at least their attempts to avoid paying for insurance claims. I am sure she has seen it all and worse.

So, let's recap. Radiology calls to have PET scan pre-approved. Insurance company says it does not need to be pre-approved. Linda has PET scan. PET scan claim is denied. Insurance company says PET scan needed to be pre-approved and now needs to be post-approved. Radiology calls to have PET scan post-approved. Insurance company says PET scan is not covered and won't let radiology post-approve the PET scan.

I call the supervisor of the department in radiology that gets procedures pre-approved. She pulls up my file. She points out that they have tried twice now to have my PET scan authorized and the insurance company refuses to let them. "I don't know what we can do for you at this point." Well, I hate to say it but I got a bit teary eyed as I begged her to help me. I pointed out that I had no idea that to do at this point either. She took pity on me and said she would give a call about my dilemma to a supervisor in the billing department that she knew. She said that since it was later in the day in the mid-west but she would let me know if she heard anything.

At this point I decided to get our company benefits coordinator involved also. I wrote all of this up and sent her copies of my claim denial and radiology invoice. She talked to someone with the insurance company who asked her to send over my medical records. Hey, how about that, someone at the HEALTH insurance company agreeing to finally see my HEALTH records!

I called the supervisor of the department in radiology that gets procedures pre-approved. She had not heard anything from her billing department so was very happy to send over my medical records. And get me out of her hair.

I called the billing department of radiology and explained where we are on everything and was told that they would delay the date of my first payment by a month!

It took two weeks but I did get word from our benefits coordinator that the insurance company has agreed that it was a medically needed a procedure and that it will be covered! WooHoo. But they are waiting for an out of state adjuster to take a look at it before they send any payments out. What?!?! I am trying to be an optimist but it has been a week and everything still says that the claim is still rejected.

So, stay tuned. I might be making some more phone calls. I hope I get Carolyn again. I bet she remembers me this time.

This is just the most recent egregious example I have of my insurance wars. At least now I am feeling well and just have the one problem. Back when I was in treatment, I was receiving up to twenty bills a week. It was impossible to keep track of everything when I was so sick. I figure I paid over $1,000 more than I should have but I just didn't have the strength/energy/mental accumen to play these games.

Shame on insurance companies. To take advantage of people when they are at their lowest like that is just inexcusable.