Who is responsible for a medical insurance claim denied weeks later

[insuranceclaimissue]

Jurisdiction

Illinois

I have a difficult medical condition that makes mobility a real problem. I had to go to a doctor, who gave me a scrip for therapy to try to avoid surgery. 2 weeks later I get a letter in the mail telling me that I'm denied for coverage because the treatment was not medically necessary. Of course it was. It isn't cosmetic or anything unnecessary. I can't walk properly and get to work or go anywhere else. The denial is ridiculous.

I call up the insurance company and I'm getting a story that the doctor didn't send over some notes and that might be the problem, and he has to send them. The doctor wrote me a scrip for the PT. Why should I be responsible for this? I don't control any part of this relationship and it's impossible to know what isn't going to be covered and why. If it takes many weeks to find out that the insurance company has a problem and that only happens AFTER I went, then how can anyone know that they might be denied for coverage later? If you have to wait that long also to find out, then it is weeks you can't walk until the doctor and the insurance company can figure this out. The whole medical care system stinks and even one of my doctors called it a scam.

 

[justblue]

I have a difficult medical condition that makes mobility a real problem. I had to go to a doctor, who gave me a scrip for therapy to try to avoid surgery. 2 weeks later I get a letter in the mail telling me that I'm denied for coverage because the treatment was not medically necessary. Of course it was. It isn't cosmetic or anything unnecessary. I can't walk properly and get to work or go anywhere else. The denial is ridiculous.

I call up the insurance company and I'm getting a story that the doctor didn't send over some notes and that might be the problem, and he has to send them. The doctor wrote me a scrip for the PT. Why should I be responsible for this? I don't control any part of this relationship and it's impossible to know what isn't going to be covered and why. If it takes many weeks to find out that the insurance company has a problem and that only happens AFTER I went, then how can anyone know that they might be denied for coverage later? If you have to wait that long also to find out, then it is weeks you can't walk until the doctor and the insurance company can figure this out. The whole medical care system stinks and even one of my doctors called it a scam.

Did you have a legal question, or did you just want to vent?

FWIW: You need to do whatever is needed to make sure you can get the medical services needed. It can be a PITA, I agree... but in the end you are responsible for you.

 

[cbg]

Yes, I agree that the health care system in this country is broken. But it's not going to be fixed any time soon (certainly not in the upcoming administration) so we have to deal with what it is and not what it should be.

You have two options.

1.) You can talk to the doctor and have him send/resend the notes that the insurance carrier requires, and maybe get the claim paid;

Or

2.) You can do nothing and not have the claim paid.

Sounds like a no-brainer to me.

 

[Tax Counsel]

Yes, I agree that the health care system in this country is broken. But it's not going to be fixed any time soon (certainly not in the upcoming administration) so we have to deal with what it is and not what it should be.

You have two options.

1.) You can talk to the doctor and have him send/resend the notes that the insurance carrier requires, and maybe get the claim paid;

Or

2.) You can do nothing and not have the claim paid.

Sounds like a no-brainer to me.

There is a third option: get copies of the documents the insurance company wants and then you provide them yourself to the insurance company. Federal law gives you the right to get copies of most of your medical records so the doctor may not stonewall you and refuse to provide them to you. Your contract is between you and the insurance company and it is your obligation to provide the proof that you are entitled to benefits under that contract. The doctor or other medical provider is not legally obligated to provide that stuff for you, although the insurer's contract with the medical provider might require it. The problem is that you aren't a party to that contract. You are a third party to that contract and that limits what claims you can make based on that contract. If you provide the proof and the insurer still refuses to pay then you probably have everything you need to successfully sue the insurer to pay the claim.

 

[Red Kayak]

I call up the insurance company and I'm getting a story that the doctor didn't send over some notes and that might be the problem, and he has to send them. The doctor wrote me a scrip for the PT. Why should I be responsible for this? I don't control any part of this relationship and it's impossible to know what isn't going to be covered and why.

The doctor's staff provided wrong/incomplete information.
Contact the doctor's office and ask if they have remedied this. They probably are working on this already, since they want to be paid.