Insurance appeals

[Deanne]

Have you had to submit an appeal to your insurance company? If so, how did it go? I received a stack of stuff from my insurance company showing they will only cover a small amount on the labs I had run while I was on dialysis. I talked to the dialysis center in March (I received these in February). The dialysis center social worker said to hang onto the checks that came with the paperwork and send them to the lab when I received a bill from them and that would be the end of it. I wasn't comfortable with this because the checks only covered the small amount that the insurance company said they would cover.

I haven't heard anything from the dialysis lab yet and the time is reaching the end of the time allowed to appeal the claims, so I called my insurance company today. The insurance company said the lab is out of plan for me and I will owe them the full amount, into thousands of dollars. The checks are to cover the small amount that the insurance company will cover and this amount will be included in the amount the lab will bill me.

I started the appeal process with the insurance company. I never knew where the labs were being done. My blood was drawn at my dialysis center, ordered by my doctor. They are in my plan.

I am supposed to get an answer from the insurance company in 30 days. What happens if they deny the claim again? How does Medicare affect all of this? I went on Medicare the day I started dialysis, but this claim is all coming through my primary insurance company - BCBS. I've never seen anything from Medicare other than the quarterly bills.

[nursey66]

I have dealt with a lot of insurance issues , but have not had to do an appeal yet. This is what I do know about Medicare. They cover all labs 100 % no matter what clinic does the work. Medicare does not have "in plan  & out of plan " Clinics,Hospitals, etc. They should pick up you labs if the denial is there by BCBS, however, with the Bundle thing they have going now with Dialysis, and I think Labs are part of it , [not really sure]  they may not want to cover since they didn't pay for the original Dialysis. I would argue that point with them if it came to that !!  I would certainly give Medicare a call about it.  You would have to have Part B of coarse, not just the hospital part A.  I would think anouther recoarse would be the Dialysis site.  Since your ins paid them, and they "farmed " out the labs, they should pay the lab and then add the amount to your bill from the dialysis site.  At least thats what my Hubby's clinic and hospital did when he was on my ins from work.  They would send lots of his labs to Mayo Clinic, that was not on my ins. plan.   But the bill was paid to Mayo by his clinic, and we were billed by his clinic and my ins covered it that way.   I used to work in as a clinic nurse before I retired & was required to do a lot with ins. companies.    They can be bruttal, but ask for a Superviser when you get no-where.  That often will help. Hang in there ,kidney patients have enough problems !!!

[Deanne]

Thank you for that awesome information! I was imagining spending the rest of my life trying to pay off this bill. I have hope for a better resolution now.