Any insurance pros here?

I need help with an appeal Re: Usual and Customary denial

I am so frustrated and I don't know what to do.

We're apparently being charged nearly $1000 for Sadie that we shouldn't be charged for. Her delivery should have been completely free for her (her part, not mine), according to our insurance. And it was for Hannah, but so far not for Sadie. I am going nuts here because it makes no sense at all. I just got a letter about appealing, it's 4 pages long, so I guess that's my only option, I just don't understand why it's messed up in the first place. I called someone yesterday and they said the doctor over charged because they are in the 75 zipcode and we are 76. I think it means it's out-of-network? But it's not even my pediatrician, it's just whatever doctors do the routine care at the hospital! So I'm extremely frustrated with this right now. Obviously, I would NEVER choose an out of network doctor. I didn't have a choice with these, it's just who is there. But we didn't have a problem with Hannah, so why now?? Anyway, I already appealed one of those and the appeal was rejected so I'm not very hopeful about this. Do I have an chance of the appeal going through? I don't even know what to say. Here's the other dumb thing, Sadie wasn't even a patient in the hospital for 24 hours. She was discharged at like 16 hours old... so her bill should be much much much less in the first place. I don't get it.

Thanks for letting me get that out.

I work for a health insurance company, but unfortunately I work on the Medicare product, not commerical.

First of all, when you became pregnant did you call the insurance company and tell them? Did you call and get pre-authorization for the hospital? Did the insurance company advise you that you could use the hospital of choice? When you registered at the hospital and you gave them your insurance information, did they advise you that their rounding pediatricians are not par with your insurance? Were you given the option of having your own pediatrican come in and see the baby?

The trick with writing appeals is to give good facts and be non-emotional. Say step by step what you did to ensure that the service would be covered. Document anything you were told by the insurance company. Document anything you were told by the OB/GYN/Midwife. State what services you were told would be covered. If you want me to look over your appeal you can PM me.

Now, I would be ready for a possible denial by the insurance company. Just in case. Call the hospital and tell them you've been notified that the insurance company that they don't want to cover the charges. Explain that you are appealing and that you were under the impression from your summary of benefits that your daughter would be covered. Ask if you can negotiate to pay what the insurance company would normally stay for a health infant's care for less than 24 hours. You can ask the insurance company for what they would pay for this care (they may not tell you, but if you have the bills from your first delivery you can use this for your referrence) Try to negotiate down your bill and tell the hopsital you want to pay. Now, if the hospital won't work with you then tell them you have financial hardship and will be sending them $10 a month because that's all you can afford. Odds are they will work with you.

PM me if you want more help.

Thanks for the info. I might pm you when I get my appeal going!

I guess the thing that makes the least sense is that my 2nd daughter was born at the same hospital, with my same OB and everything. And I did choose my ped to come and do the rounds. I am not sure what charges they are talking about--I think just the nurse care? Maybe all the extra little things that happen? I don't know. But thanks for your response.

We had major issues too with the bills from my son's delivery. For example, he was charged for the nursery even though he never stayed there (we were told they charge everyone.)

The kicker was at first the insurance company said he wasn't preapproved. When I remarked that I was preapproved to go into the hospital to deliver a baby, why were they surprised when I had a *gasp* baby? The lady on the phone actually laughed and they finally approved everything.

Sorry you are going through this - it took about 6 months for the hospital and the insurance company to finally settle everything.

well if you had an auto/home insurance problem, i could help. lol

good luck hon!!!

It sounds like it was a mistake at the hospital in how they submitted the bill to insurance? If so, have you tried checking with the hospital to see if they can correct the problem?

I'm not an expert, but ... Usual and Customary means that they have a maximum fee that they will accept based on what is considered the "usual and customary" charge for your area. Based on what you wrote, it sounds like the zip code you live in has lower usual and customary fees than the zip code that the doctor is in where the services were provided. So, let's say the insurance company allows $1000 for the doctor's services for your zip code, and the doctor charged $1200 - so that is $200 more than is "usual" for where you live ... then they are only required to pay based on what they'd pay of the $1000, and you get the rest.

I'm not sure how to appeal it though. I don't think it's an out-of-network thing ... I'm assuming you're seeing an in-network doctor, right?

I have 12 years in the insurance industry (including nine in management), but no in healthcare. First off, consider calling the hospital to see if they will waive the difference. It appears that the hospital is over-charging what is typical for the zip code. Secondly, you may also submit a complaint to your local insurance commissioner and they will research the validity of the denial. Good luck! Sorry it's so frustrating!