They said she was covered, but they would not pay the billl [i]
The patient nearly fainted when she opened her bill from the surgical center where she recently had sinus surgery. As she understood it, the insurance company said pre-approval was not necessary. The provider performed the surgery.
She had expected to pay the balance of her out-of-pocket share, not the $32,000 demanded by the medical provider when her bill arrived several weeks later.
For more than eight months she called both parties, trying to get resolution. And the provider continued to demand payment in full. Finally, an intervention by The Star-Tribune created a settlement.
The insurance company blamed the provider for errors in coding. The provider blamed the insurance company for messing up the paperwork and losing their appeal when the insurance company denied payment. During the time they battled, they shut out the patient, as she fretted over how to pay the debt she didn’t owe.
How many individuals do you know – employees, friends, relatives – who have received what they viewed as unfair bills, not because they went out-of-network for care, but from a covered provider for a service that appeared to be covered under the health plan? It does happen, and at Dattilo Consulting, Inc., we hear about them from frustrated clients.
“We may hear about these disputes maybe once a month, but we suspect they happen more often” said Paul Howard, the compliance specialist at DCI. “Usually, the problem is that a patient doesn’t know how to get through to the right person,” Howard said. “We do.”
The patient in the story kept copious notes about her frustration in talking with various customer service representatives. As each blamed the other, she didn’t know how to resolve it. All she knew was the $32,000 bill hanging over her head. She needed help.
No one should need a newspaper reporter to write a story about his or her plight to get relief. When that story appeared, however, the insurance company quickly paid the claim – all of it – and finally, the patient could relax.
He suggested that any client who is struggling with getting a claim settled should call Paul Howard at DCI. “Paul has been doing this work for more than 27 years, and he knows how to break through.”
The person in the story did not work for a DCI employer client, but if she had, “We certainly could have helped,” Howard said.
To contact Paul Howard about a claim problem: 952.448.8800
[i] Portions of this narrative are taken from “Medical Relief, $32,000 bill grief,” by Christopher Snowbeck, Minneapolis Star-Tribune, 4/18/2024.
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