Should I hire a lawyer?

Okay, on January 5th I went to the ER aspect my surgeon due to pain around the lap band area. They did emergency surgery. A week ago I got a letter saying they wouldn't approve the surgery due to the fact that the doctor was out of network. He isn't so I wasn't too concerned. Yesterday I got a letter saying they are denying my claim due to the fact the surgery wasn't medically necessary and that I am responsible for payment. Apparently it has already gone through the peer review and was denied. My only option is to appeal. I truly don't understand how it is on me? I didn't tell the doctor to take the band out! 

So what do you all think?

Hello: I work as a nurse reviewer for an insurance company. 

Generally speaking, out of network emergency care is covered by many insurance companies. Are you sure the provider was in-network? I would suggest doing a search on your insurance's website under their "find a doctor" area; most companies have a search function on their websites that let you find a provider. Find the provider's name and see if they're currently in network. Remember: sometimes insurance companies don't update their websites all the time and someone who looks like they're in network may not be. It also depends on the plan you have. Just because you have Company X as your insurer, you may have a policy under which this provider is NOT in network, and someone else under Company X may have this provider in their network because it's a different plan.

Definitely do an appeal. The letter you received should have given you instructions on how to appeal. You may have to call the customer service line and have them walk you through the exact steps. Get the provider who did the surgery to provide all the medical records about your case to the company.

Good luck,

cheremiste

Thank you cheremiste!

An insurance appeal has several levels and upon initial denial, the hospital would be required to provide additional documentation that deems the surgery medically necessary.  If they cannot do this, then the surgeon must.  He is responsible to provide that additional documentation that helps the insurance carrier understand why he did emergency surgery on you   I would not stress too much.   Hospital bills "drop" three days after your discharge date and your EOB from the insurance carrier will give you a denial with a code, but indicate you are responsible.    These types of claims can remain "open" for months, going through the appeals process.   I would call the hospital, ask for Medical Records and find out if they have provided additional documentation to your insurance carrier.  If they have not, call the carrier and ask them what specifically they need to be able to pay the claim.   Truthfully, the hospital should do this, but if you are worried, this is what you can do to help it along.   

Even if the Doctor was out of Network, it should be covered if deemed medically necessary, just at a lower percentage than an in network Doctor.   

Good luck! 

Nik H thank you for your reply!

I agree you should appeal, or at least get a satisfactory answer.

i was self pay for my band because my insurance didn't (and still doesn't) cover WLS.

i had to sign indicating my understanding that if this device ever has to be removed, by choice or by medical necessity, that I would have to pay out of pocket for it.

i paid for surgery, then saved for reconstruction, then started saving for possible removal.  I have an HSA and I contribute the max allowed, because even. At 7 years post op with no complications, the chances are high that at some point the band will need to come out.

i hope you get some answers and help in getting your removal covered.

I'd say that when you look on line, and if you find that surgeon is shown as in-network - do a screen print and save that info as proof.

Websites are often not updated so that is not sufficient proof.

Thank you everyone. I called today and after a long time on the phone they said they have two claims open for that date; one approved and one denied. Apparently they didn't use the name BC/BS recognizes them under and they didn't code the procedure as an emergency. Last they put in that I stayed overnight which I didn't. Supposedly this is going to straighten it out. I will keep you posted. Thanks for all your replies.