Before surgery, my insurance company said I wouldn't have to pay. After surgery, that's changed. What now?
November 2, 2011 3:08 PM   Subscribe

Before having surgery, I was told by my insurance company that my deductible had been reached, and that there was nothing for me to pay. After surgery, they amended that, telling me that in fact my deductible had not been filled at all for the present period, and I *would* have to pay. Am I just screwed here?

The short version of a long story:

I recently had surgery to deal with a staph infection in my sinuses. Prior to surgery, my ENT's office contacted my insurer, Horizon Blue Cross Blue Shield NJ, who told them that my deductible had been reached for 100% for the year - my ENT's office passed that information onto me, and I went ahead with surgery. (The deductible having been reached made sense to me, given that I have dealt with several medical issues this year, including diagnosing and treating sleep apnea.)

After surgery, my ENT's office contacted me, very apologetically, telling me that HBCBS was now giving very different information. I called their helpline yesterday, and after an extended series of representatives, finally got HBCBS' story:

* My ENT's office spoke with their Provider Services department - Provider Services "isn't allowed" to say exactly what my deductible is, and can only provide an estimate, which they, according to HBCBS, told my ENT's office was an estimate.

* The 'estimate' they gave my ENT on how much of my deductible had been applied? 100%. The actual amount that had been applied? 0%. (The person I spoke to said that his guess was they checked 2010 instead of 2011.)

* Given that Provider Services was just providing an 'estimate,' and my contract apparently specifies I need to research the deductible directly with the insurer (i.e. not through my doctor acting as an intermediary), nothing against-the-rules has taken place here.

I'm going to have to pay somewhere between $1250 and $2500, at a time when money is on the tight side. To be clear, this could be much worse (I'm incredibly grateful that I'm not on the hook for tens of thousands of dollars or more), but I can't believe that it's okay for them to give blatantly inaccurate information to my ENT's office and then change their tune.

Am I just screwed here, and need to pay up? Are there any options that don't entail going down a legal route I will almost certainly lose? Thanks for your help here.
posted by Ash3000 to Health & Fitness (15 answers total)
How can 0% have been applied to your deductible in 2011 when you have received diagnosis and treatment for several medical issues this year?
posted by grouse at 3:15 PM on November 2, 2011

grouse - Apparently, there are exceptions to what is explicitly covered by the deductible, and all of my prior claims fall under that umbrella. E.g. All diagnostic procedures are not covered by the deductible, so my sleep study to check on apnea doesn't count.
posted by Ash3000 at 3:16 PM on November 2, 2011

Insurance companies are very quick to point out that pre-qualifications and estimates provided to medical providers are non-binding. Your medical provider will be very quick to point out that you are liable for all charges regardless of what your insurance company provides fora pre-qualification or estimate. In short, it doesn't really matter what your insurance company told your medical provider, it matters what your insurance policy says.

You need to find the details of your policy. It will provide details of what does and doesn't apply to your deductible. It's not as if the insurance company can make the rules up as they go along. If this is an employer-provided policy, it may be worthwhile to engage your employer to provide some weight behind your question. However, in the end, this question is entirely determined by how the deductible on your policy is fulfilled, and you can only get that information from the policy and not from us.
posted by saeculorum at 3:20 PM on November 2, 2011

Oh wow, that is a really bad deal! But unfortunately, if the deductible really hasn't been met, then you will have to pay up.
posted by Eicats at 3:22 PM on November 2, 2011

Read your policy, you might have separate deductibles for office visits, and then for surgical/hospital stuff. Mine is something like $250 for routine medical, and completely separately they will pay 90% of surgical/hospital until I have reached something like $3000 out of pocket for the year, then it's 100% after that.
posted by gjc at 3:25 PM on November 2, 2011

I would get all the policy information, what 2011 services were applied to your deductible, your estimation of benefits from each service for the year, as well as the dates and contacts for all the back-and-forth between the carrier and your ENT's office. I would then call the carrier and make the case that you went ahead with an expensive procedure based on their pre-certification/estimate of costs. If you run into resistance or they revert to a default script, escalate, escalate, escalate. Insurance companies COUNT on your confusion and then backing down. If you push to the next level, they almost always make some sort of "adjustment". I speak from lots of experience, unfortunately.
posted by thinkpiece at 3:48 PM on November 2, 2011

Sorry, I meant "Explanation of benefits," not estimation.
posted by thinkpiece at 3:49 PM on November 2, 2011

You can also say that if you had known the procedure wasn't fully covered because of your deductible, you may have shopped around for a less expensive provider!
posted by thinkpiece at 3:50 PM on November 2, 2011

I have found BCBS in more than one state refuse to pay a claim stating various reasons why it isn't covered, then upon second submission of said claim suddenly finding new information showing the claim can be covered. This seems to be SOP for them.

Gather all claims and Explanation of Benefits forms for every claim for the entire year (either from the website or make them send them to you) and review each one to see what was applied to the deductible and what wasn't. You may find some mistakes just by doing that. You should also review your policy to determine what applies to your deductible and what doesn't. I cannot believe that any of the medical appointments you had this year (leading to SURGERY FOR STAPH INFECTION for Gods sake) wasn't covered at all. something sounds screwy there.

I'd also ask your doctors office to resubmit the claim and see if it's denied again. My mom had nearly the exact same thing happen for shoulder surgery (she even checked her benefits by phone herself) and submitting the claim a second time magically fixed everything and it was covered.
posted by MultiFaceted at 4:13 PM on November 2, 2011 [1 favorite]

Important: when was the start of your current plan year? Many plan years start in the middle of the year vs. on January 1 of each year. The deductible usually resets on that date, too. If you don't know the start date of your plan year, ask your HR person (or spouse/parent's/partner's HR person) - assuming this is an employer-sponsored plan. If this is an individual plan, check your contract, call the insurance company, or call the insurance agent who sold you the plan (if there was one).
posted by pecanpies at 4:59 PM on November 2, 2011

Call your insurance company and ask them to explain what happened and why. That's pretty shoddy. You might have waited until next year to have the surgery. They gave wildly inaccurate information, and they probably call your plan some form of managed care. Explain that you now have a large, unexpected expense, and ask them if there's anything they can do for you. Be really nice and polite, as of course you would be, but also remind them that you are now in a bind. I don't know if they can make adjustments, but it's worth asking. Also, every state has an insurance commission, and you could call and ask them what your rights are. They'll be somewhere on the Attorney General's web page for your state.

I hope you're feeling better.
posted by theora55 at 5:50 PM on November 2, 2011

If you find that you really do owe the money, pay the deductible as you can. Don't put yourself in a bind paying it all at once.
posted by shoesietart at 5:58 PM on November 2, 2011


Two things:
  1. Insurance companies will screw you if they can.
  2. They always can.
You should deal with them exclusively in writing, and insist that they respond to you in writing. If (as is likely) they persist in calling you to "work things out," get the name and ID number of the person you spoke to, and immediately after you hang up, write down what they said in the form of a letter to them: "Thank you for having [INSERT NAME] explain [WHATEVER] to me. S/he stated that [WHATEVER LIE THEY TOLD]. I will [WHATEVER YOU'RE GOING TO DO NEXT]."

Send the letter, keeping a copy for yourself.

When you're tired of the runaround, take the letters to a lawyer and/or the insurance commissioner (or both).

Good luck.
posted by spacewrench at 6:30 PM on November 2, 2011 [1 favorite]

I would talk to a patient advocate. These are organizations often made up of nurses and insurance experts that you can authorize to directly deal with your health insurance company. My employer provides access to a health advocacy service, as do many, since it lowers the cost of health care.

For individuals, there's a service called HealthProponent that is affordable.
posted by metl_lord at 7:04 AM on November 3, 2011

I once had an insurance provider (UHC) start improperly claiming an in-network provider was out-of-network THE VERY DAY my in-network deductible was met. It took weeks of calls and letters to sort it out. I am convinced that they did this on purpose and were just hoping I wouldn't notice.

I also once had BCBS utterly refuse to pay $800 in bills because we had supposedly exceeded the allowed number of provider visits, even though we'd already had the extra visits approved in writing by BCBS. That issue was, unfortunately, never resolved because BCBS refused to admit a mistake and I did not want to pay for a lawyer as it probably would have cost me more than the bill, so I wound up negotiating with the healthcare provider for a discount and paying.

My point is, as others have said, insurance companies will try to screw you over and they will do so frequently and blatantly. They are counting on you not paying attention, or being too lazy or too busy or too sick or too poor to fight. Because they've won that bet many times over.

If it's worth it to you, be a squeaky wheel. Check your policy, as others have said, and try to figure out whether your deductible was actually met, because they may be lying to you. If you can prove you're in the right, and be persistent, you may get results.

If you can't prove it or they won't listen and you can't afford to lawyer up and make them pay, try negotiating with your doctor for a discounted bill or at the very least a monthly payment plan. Just explain that you had not budgeted for this expense because your insurance company misled you. Don't be embarrassed about it, either. These sorts of insurance company shenanigans literally happen daily and you surely won't be the first person your provider has seen screwed over by BCBS. Health care providers often offer discounted rates to people who are having insurance issues.
posted by BlueJae at 7:59 AM on November 3, 2011

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