Question:
Had preauthorization but claim not paid post op by MMOH Super Med plus-

I recieved my letter of Preauthorization APril 8th from Medical Mutual Super Med Plus. I am 6 weeks out and recieved my EOB's today and $5000 of the hospital bill and ALL of the surgeons bill are unpaid $7200 total ing 12,200+ dollars. I AM FREAKING! I am 6 weeks out! I even have an email from MMOH stating I only had a 100 dollar deductible!!! HAs anyone ever had a claim NOT paid post op? The EOB says this decision was based on "internal medical guidlines" OH GOSH-I fought with MMOH for MONTHS and WAS approved. I was also approved January of 2000 and did not go through with the surgery!!! HELP!    — Lisa K. (posted on June 3, 2003)

June 3, 2003
Unless you recieve a bill from the hospital and doc don't worry about it. Usually the ins. contracts with the hospital for a certain amount and that is what they pay. You cannot be billed the balance if this is the case. My surgery was 18,000 and my ins. only paid 6800. I was scared to death because my surgeon charges this much. That was the amount shown on my EOB. I contacted the insurance and was told my insurance paid the contracted amount and I was not responsible for the balance. The surgeons and hospitals know this when you have your surgery. When they sent your surgeon the approval, they probably also told the amount they would pay. So don't worry unless you recieve a bill.
   — Delores S.

June 3, 2003
If your insurance did not pay ANY of the drs or facility claims, you need to call the insurance company and find out why.. don't go by what the EOB says. Explain that your surgeon sent in a pre-determination request and you were approved which mean that the bills should have been paid... except, of course, for your coinsurance. If, as the poster below stated, the EOB shows the original charge, the approved amount (the allowable) and an amount that the insurance paid, you are not responsible for the difference between the original charge and the allowable.. the surgeon has to write this amount off because he is contracted with your insurance. If I received a denial such as you describe in the dr's office where I work, I would be on the phone to the insurance company asking for an explanation. I imagine your dr's office will be doing just that.
   — Bonnie

June 3, 2003
What Delores stated is correct as long as the doctor or hospital has a contract with your insurance. If not, then you may be liable for the difference of what they paid versus what was billed. Are you sure you used an in-network surgeon or one that has a contract with your insurance? It could be as simple as the claim did not reference the pre-approval, so don't freak yet. Start by doing calling and find out what the problem is.
   — zoedogcbr