Author Topic: Help to get Insurance / hospital to reprocess claim  (Read 595 times)

Offline KidOOO

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Help to get Insurance / hospital to reprocess claim
« on: November 03, 2016, 12:11:47 PM »
If there's anyone here who can help my friend with the following issues or knows of someone who can help (Would pay for resolving this). It's a bit long and I hope i explained it correctly

The Story:
He has insurance with a high $6850 deductible. once deductible is hit insurance covers everything no co-pays

He needed to do a medical infusion which hospital would bill in excess of $50,000 retail. hence that procedure would leave him with a $6,750 bill (for the deductible) and the rest would be covered by insurance

Now the drug being infused is the main cost (retail upward $30,000), so the drug manufacturer has a program aimed at high deductible health insurances, where they offer to cover the entire out of pocket cost of the drug minus the first $50. (They are essentially paying the hospital who then pays it back to them for the drug cost, and then the insurance pays the rest)

So he figured after all said and done this would cost $50 (Hospital bills $50K, insurance pays everything minus $6850, drug manufacturer pays $6800 = $50 balance).

The problem:
well of course somehow he ended getting a bill for  $1700.

The insurance / hospital did the following: they split the procedure into 2 parts and applied part of the deductible to each part as below

1. The hospital service of performing the infusion - discounted cost - $1700 - deductible applied - $1700
2. the drug itself discounted cost - $18,500 - deductible applied - $5150

Now since the drug manufacturer program only covers the drug portion, they only paid the $5,000 deductible (for part 2). leaving him with a bill for $1700 deductible for the first part.

The question:
If there was a way to get the hospital / insurance to reprocess the claim in a different way,  they would not pay a cent more, but the drug manufacturer would then cover the $6700 deductible applied towards the drug, as below

1. the drug itself discounted cost - $18,500 - deductible applied - $6850
2. The hospital service of performing the infusion discounted cost - $1700 - deductible applied - $0

In both cases the insurance ends up paying $13,350

He already tried calling the hospital and the insurance and they do not want to adjust anything. any help here on how to get them to reprocess or anything else that can help would be appreciated.

Thanks!


 
« Last Edit: November 03, 2016, 12:19:51 PM by KidOOO »

Offline dealfinder85

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Re: Help to get Insurance / hospital to reprocess claim
« Reply #1 on: November 03, 2016, 12:21:13 PM »
im very confused, but if you want them to reprocess to eliminate his $1700, who does he want to cover that amount? you say insurance isnt paying it. but someone has to

Offline LoLo

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Re: Help to get Insurance / hospital to reprocess claim
« Reply #2 on: November 03, 2016, 12:33:29 PM »
im very confused, but if you want them to reprocess to eliminate his $1700, who does he want to cover that amount? you say insurance isnt paying it. but someone has to
The drug company. IIUC.

Offline KidOOO

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Re: Help to get Insurance / hospital to reprocess claim
« Reply #3 on: November 03, 2016, 01:01:26 PM »
im very confused, but if you want them to reprocess to eliminate his $1700, who does he want to cover that amount? you say insurance isnt paying it. but someone has to

Yes, if the insurance paid the $1700 for the first part, and then paid $1700 LESS on the 2nd part, the drug company would then cover an extra $1700 since it is going towards the drug

Offline KidOOO

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Re: Help to get Insurance / hospital to reprocess claim
« Reply #4 on: November 10, 2016, 09:39:12 AM »
Anyone?

Offline Yoel F

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Re: Help to get Insurance / hospital to reprocess claim
« Reply #5 on: November 10, 2016, 10:48:25 AM »
Did you ask the Hospital billing dept. to do it ?
I don't think they would be willing to do it.
If for all other patients they bill it separately and here they do it different, it might be against their billing policy and 'maybe' considered fraud.
I'm not a professional, just my humble opinion.
 

Offline username

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Re: Help to get Insurance / hospital to reprocess claim
« Reply #6 on: November 10, 2016, 10:48:59 AM »
Probably need to speak to someone at the hospital face to face to see if they can re-bill it.
Perhaps if the hospital has a financial assistance office, they can help.
^^^