Question:
Are there any Insurance claims guru's out there that can possibly help me ??
— tannedtigress (posted on September 12, 2002)
September 12, 2002
Hi Dawn, I hope this helps... Send a copy of your receipt, to your
insurance company (with a "cc" to the doctors and hospital)
showing that you paid the $2808.00 and that you are paying the remainder of
your "out of pocket" expense of $792.00 and that it is your
understanding that your insurance is to pick up the remainder at 100%.
Wait a week and then call your insurance company, but when you send it get
a name of an individual to direct your letter to so that you have a
particular person to call....I haven't had the WLS yet, but I too have the
same type of insurance through Cigna. I hope I don't run into the same
situation but if I do, then the above is what I will do. Good Luck!!!
— Regina S.
September 12, 2002
I worked in insurance health claims for years. It is very difficult for
people to understand that when the Dr and Hosp bill the ins co they do not
indicate what you have already paid. The ins co takes the first bills
received and applies the deductible to that bill. So if the surgeon bills
first the whole $3600 out of pocket is going to be left on his bill and the
remainder of all eligible (key work eligible) expenses should be at 100%.
Now another problem could be that you Dr bills over reasonable and
customary charges for the area that you are in. That balance would be
payable by you. I know that it is all confusing just when you see balances
on your Explanation of Benefits subtract what YOU know you already paid
because the insurance company does not know.
— Peggy A.
September 13, 2002
Hi Dawn,
You may want to check this out and see if this is your situation -
sometimes when you pay in advance as you did (this money is kept temporarly
by the doctor)- hince the term deposit - then the doctor goes ahead and
bills the normal rate to the insurance company. Once the insurance company
pays at their 75% rate then the doctor reimburses you the overage of the
total payment he received. Check with the ins. company to see if they've
sent payment if they have contact your doctor and they'll most likely
re-imburse you with no problems. This works the same way for the hospital
also. Until the doctor bills the ins. company and then the ins. company
pays the doctor your basically left in limbo - money wise anyway. Hope
this helps. Linda
— lindajenkins
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