Question:
I'm post-op and now my surgery is being denied.

HELP!!!!! I am 5 months post- op and now all of sudden my surgery is being denied. Prior to surgery I had a pre-certification from UHC of Ohio and they approved the surgery. I still have my approval letter. BTC of Ohio has appealled on my behalf, but the claim was denied. Now I have to write an appeal letter. Has anyone else had to deal with this post-op and if so how was the outcome? I could also use some tips on what to include in the appeal letter. Thanks to all already. UHC wants me to pay upwards of $25,000, and I can't afford that. Any suggestions out there? Please HELP!!!    — ohjenifer (posted on January 29, 2004)

January 29, 2004
Are they denying the claim entirely on only paying a portion? BTC is considered out of network by most insurance companies and therefore you would have to pay the out of network costs which is normally a %% (30% or so) of Reasonable and Customary (R&C) up to your out of network, out of pocket maximum, PLUS you are also responsible for the entire difference between R&C and what BTC billed the insurance. Just because they approved the surgery doesn't mean they are going to pay 100% of the bills - they will only pay what is required by your particular policy. You need to find out if BTC and the surgeons are in network or out of network and what portion of your bill you are responsible for based on what you find out. I also used BTC in Groveport, Ohio. I went there knowing they were out of network and I could end up owing thousands but I took the chance because I thought they were the best around. Luckily, my insurance (Aetna) paid all but 1,500.00. I don't really know why - but they paid at the in-network rates. I believe it was because the surgeon fixed a couple of other problems while he had me open (small umbilical hernia and adhesions) Good Luck.
   — Carolyn M.

January 29, 2004
Me again - Hi Jenifer - I didn't even look at the name of who posted the question before I typed my response. Other than this insurance fiasco - how are you doing? Please feel free to e-mail me privately if you'd like. Take Care, Carolyn
   — Carolyn M.

January 29, 2004
Jenifer- Also don't forget, just because they approve something it doesn't guarantee that they will payment. Have you called UHC and asked them why they are denying it? Are they needing something that maybe BTC didn't give them. Good Luck!!
   — Ashley S.

January 29, 2004
When I was a little more than 3 months out I got a letter from my insurance saying they were denying my claim also. I called my surgeons office who contacted the insurance. Someone in the insurance office incorrectly typed in my surgeons id number and he came up as an out of plan doctor and they were refusing to pay it. I was told to ignore the bill that was coming from the surgeons office and from the hospital since the insurance messed up. Boy was I glad I was told that because when the hospital bill came it was over $56,000.00 and the surgeons bill was over $3,000.00. That was 2 months ago and I have not heard anything else from either the hospital, surgeons office or insurance. I was told that it would take several months before the corrected bills would be sent to me so now I am just waiting to see what I really owe.
   — tazfan

January 29, 2004
Although I can't provide any first-hand help, here is a site I found which has great appeal letters. Even if they don't fit your situation exactly, they should be good for extracting bits and pieces. Good luck! http://mygastricbypass.com/
   — wschaffer

January 30, 2004
I am sorry for your predicament. I have NOTHING good to say about UHC. They said they would cover a procedure and the Drs. office called three different times because I told them I didn't think it was covered and three times she office was told it was. but after the procedure was done! low and behold it wasn't covered and no matter what i did or said and the Drs. office did and said they would not cover it and i had to pay for it. And mine was only for $400.00! Get a Lawyer and fight them! Fight them for all of us. I will never have them for insurance again.
   — CATHYSDAN

January 30, 2004
You have a contractual agreement with UHC. You relied upon this contract to have the surgery. UHC cannot now back out of this contract. Find yourself an attorney who will write a letter to state UHC is in breach of contract, and if the situation is not remedied immediately with UHC making full payment for the surgery, you will bring a breach of contract action. Punitive damages are not normally available in breach of contract, but if you can make an argument supporting your emotional distress, punitives (and more money) may be available. I am an attorney licnsed to practice in California, but this is general contract law and is probably the case in Ohio. Good luck.
   — Ann H.