I hesitate to post this cuz I am kind of sure that if I put it in writing it will seal my fate but here goes...  Premera approved and paid my surgeon, the surgeon's assistant, the anesthesiologist, and now the physical therapist. But....they are stalling on processing the hospital bill of $58.000. They say they need "more information" from the provider including medical history, list of treatments tried and failed, and type of implants used.

Luckily, I've worked with Dr. Pritchett for several years now and he has a record of the physical therapy, injections, etc. that we tried before resorting to surgery. But Swedish Hospital (provider who is responsible for providing info) is backed up weeks and says that they won't be able to provide this info soon. Premera says that will make a determination based on the info they do have within 45 days of requesting the info from Swedish. This feels like a major cluster...... waiting to happen.

Can they do this? Do I have any recourse to push this through quickly? What do you recommend? Has this happened to you? Not the kind of stress I need while I'm recovering.

Thanks for any info or help you can share.

Luanna

I'd put some pressure on the hospital, making it clear what the insurance is intending to do. If necessary, get a lawyer involved, since this is not a light financial matter. I would think they can speed up the process since it is time sensitive.

I have Providence and was pretty concerned about something like that happening to me.  Swedish gave me and Providence a really thin invoice with line items like "misc medical service" for $28,000 and then a bunch of other ones like it at $2,000.  I knew Providence would pay since they did in Feb, but I asked for more detail as did Providence.  However, Providence never asked me about pre-op treatments or "alternatives" looked into before surgery.  I agree with Hern, if you bug the hospital, maybe they will crank out a more detailed invoice for you.  Hopefully this will work itself out. 

With regards to the bigger picture, I know that Providence and PEBB (Oregon Public Employees Benefit Board) is questioning HR as a reliable treatment, sad.   Maybe others are too, but they shouldn't be backing down on a previously agreed-to contract.

Thanks guys. Good idea Hern putting pressure on the hospital. I have the name of the guy who is in charge of my account at the hospital. I'll give him a call this afternoon. Tin, can't understand why they want info about my medical history, treatments tried and failed, etc. If I were the surgeon, I'd be insulted and think that they were questioning my medical judgement and integrity.

I also called the insurance rep. for my group plan (for retired and ex-Microsoft employees) and she contacted Premera and said basically that we are now waiting on the hospital to provide the needed info so that the claim can be processed. The insurance rep. said to contact her in a few weeks and let her know status so that she can recontact Premera if needed.

Since they approved all the other surgery expenses, I can only assume that they thought maybe I should have had the surgery in my garage or perhaps at the local grocery store!!! GRRRRRRRrrrr....

If anyone else has any experiences or other helpful ideas please let me know.
Thanks,
Luanna

Luanna-

I would also contact your appropriate person at the state office that licenses health insurers.  I would think they could force the insurance company to extend the time to report since it is out of your hands.  It really is amazing how much pressure a state insurance commissioner can have with insurers.

Good luck.

Dan

Thanks Dan. Great idea. I'm looking at the Attorney General of Washington's site and they have a procedure for filing a complaint on insurance issues.

I'm off to fill out the form!!!  I'm also ready to contact my attorney and have him put some pressure on folks if need be. I'm sure that it will all get straightened out but being proactive can't hurt.

Luanna

Quick update: Swedish Hospital says that they have provdied the information to Premera and did so on Oct. 6th. Premera has no record of receiving the files. Swedish will contact them today and resend the medical info if need be.

Progress? maybe....Keep your toes and fingers crossed for me.

Luanna

Will do Luanna, but I am going to look funny walking.... again.

When I contacted Swedish they were pretty reposnsive, so hopefully they help get this sorted out. 

Celebration time.......... After a long delay and the hospital billing rep. and Dr. Pritchett working with the insurance company - Premera finally approved the hospital bill claim. I have to admit that I was very worried there for a while. Of course that was the largest of the bills.

Luanna

Excellent, Luanna - can I uncross eveything now? I'm starting to cramp up.

Quote from: hernanu on October 17, 2011, 02:16:37 PM
Excellent, Luanna - can I uncross eveything now? I'm starting to cramp up.

I suppose it's time. I'm sure that's what did it though...so maybe after uncrossing your toes and fingers - if you would just cross your eyes for a while now that would bring more good luck!!!  ;D

Luanna