Legal question -Maximum out of pocket Question

I have already met my maximum out of pocket for 2006 back in April.  I will be completing my 3 month pre-surgery program for Aetna on Nov. 15.  My surgeon feels like I have a good case to be accepted.  I suspect Aetna will deny, just to push surgery date into 2007 so that I will have to pay deductible and co pay.  If Aetna comes back and approves me in 2007, is there any way I can make them pay as they would have in 2006?  Of course, they might find a reason to deny me in 2007 too.  I'm just wondering  "what if". Anyone know the answer to this?

keep copies and documentation of EVERYTHING you send, and some sort of proof on WHEN you sent it. might not be a bad idea to back everything up.... if you fax something to them (which they could CLAIM they never got, regardless of what your fax confirmation says) send it also via US Mail with return receipt for proof of delivery and a signature. if they claim they need _____, don't delay... get that item to them ASAP via fax, and again back it up via mail w/ signature receipt as mentioned above. stay on top of them... I would think that as long as you have everything documented that you have done everything their policy requires, and they still delay you, then  at least you'll have a leg to stand on should it come to legal proceedings.... and don't back down.

That's not true. The nurse case managers and medical directors that review your case for medical necessity do not look for things like that... Deductibles, copays, co-insurances, etc don't go to the insurance companies, they go to the physician offices so why would they care? Your Dr's office can actually initiate the pre-cert over the phone and then a nurse case mgr will call for them to fax clinical information. I do case management and when I call something into Aetna, I usually have an answer back in days.

to Paul, Sean and sassafras,  thanks for your replies.  I will try to Fed Ex myself and make certain that I document everything.  The suggestion about getting the packet on pdf file on CD is super!  Thanks.

If you have your surgery in 2007 they cannot bill the insurance company with a date in 2006, that's illegal.  Your OOP may carryover if you have a carryover on your plan.  Check with your company and see if you have a carry over.

You might actually be surprised and might be approved this year. I know its a difficult thing to wrap your mind around, and maybe you don't want to out of fear of rejection. If for some reason you don't get approved this year, basic insurance rules are that anything you've met in your deductible starting in October, you can carry that over to the next years deductible. The out of pocket maximum is a yearly maximum, and once the new year comes, it will be wiped clean.  Hopefully you will get approved and have the surgery done this year. Should that happen, that you get to have surgery this year, if you've already met your deductible, and you've already met your out of pocket maximum, the plan should pay 100% of the contracted rate. But seeing as how I work in the self insured business, it might be different with fully insured plans. All I can suggest is to call your insurance company and ask.