Medical Bills and Insurance Confusion

How could you deny this guy anything?

If you child has complex medical issues then you probably have your insurance company listed as a contact on your phone. You probably speak to them more than you speak with some of your relatives.

We live in Pennsylvania but we went to Detroit Michigan for Tommy's retinal surgeries and have had several EUA's* there too. In the world of insurance that is called going out-of-network. And it's a big, big deal. Once you go out-of-network all bets are off and insurance payments and coverage gets tricky.

Since you are out-of-state all the insurance rules are different and your insurance company likely does not have a contract with the hospital or facility. That means their providers (the doctors) are not participating providers with your insurance either. This often results in you getting stuck with the bill for very expensive procedures.

This silly guy is worth all the work!

What can you do?
Well right from the beginning Tommy's situation was very rare and attracted a lot of attention from a team of doctors. They knew that he would need surgery and that he had to go out-of-state for the best chance at a good surgical outcome. So our retinal surgeon in Pittsburgh immediately wrote a letter to our insurance company (our primary insurance - from my husband's work). Our pediatrician also wrote a letter to our insurance company explaining Tom's medical need.

After receiving this information our insurance company granted us authorization to go out-of-network for the surgery. However, an authorization is just a preliminary OK; it is not a guarantee of payment. And your insurance company will only pay the "usual and customary amount" which will be nowhere near the actual billed amount. The numbers on those bills will make your head spin!

Then it's time for the secondary insurance to kick in! We are lucky enough to have Medicaid as a secondary insurance because in Pennsylvania they waive the monetary qualifications and allow him to qualify because his medical conditions mark him as disabled. Pennsylvania is one of only a few, so called, Medicaid waiver states. I don't even like to think about where we would be without this secondary coverage.

When Thomas has medical services in Pennsylvania we are covered 100% through both of our insurances, even for prescriptions. This has been a blessing because glaucoma drops are very expensive. A tiny bottle that you go through in a month costs $120.00 and we are on two prescriptions! And then we have Tom's g-tube supplies...I don't even know how much those cost. Plus his contact lenses...

Bills, Bills, Bills
I have been on the phone for hours this week trying to decipher bills that we have been receiving from Tom's care in Michigan. One bill is from September 2011, and one is from spring of 2010! I could see on both bills that our secondary insurance was not billed. When I asked one billing office they said they tried 3 times to bill our secondary but they were denied. When I called our secondary insurance they said they never got the bill so how could they have denied it!

After endless calls back and forth it we believe that one bill will be resubmitted to our secondary insurance. Since the date of service is very old (there are rules about timely billing) it will be denied and then I will have to file an appeal. Some very lovely customer rep at my secondary insurance has offered to help me file the appeal since she has been working on resolving these billing issues with me. She has been a godsend. Sometimes you get help just when you need it!

The other bill is for anesthesia services from September 2011. They never even attempted to bill our secondary insurance because it is an out-of-state Medicaid! She came right out and told me that on a recorded line! Basically, they know that they have no contract with PA Medicaid and that the bill won't be paid anyway so instead they tried to bill me. Well I don't make the rules and I'm not going to pay that bill just because they don't want to bill correctly!

This hospital has a lot of out-of-state and international patients because this is the place to go for infant retinal surgery. They could fill out the paperwork to become participating providers so they could bill but evidently they have not.

I used to work in hospital billing about a billion years ago and I know that is routinely done. The hospital I worked for had agreements with Medicaid for several neighboring states. I also know that in these cases they usually just write off the service because it's a lot of hassle for not much revenue. But I think that often times they bill families and just see who will try to pay the bill. It's not right and it adds so much stress to families that are already struggling with so much. And think of all the people that don't have the time or the know how to fight these bills!

These bills are so big it is laughable!

Oh well. The fight continues because there will be more procedures and more bills. In these recent struggles we had two very wonderful people help us out. One was the customer rep at our secondary insurance and one was an incredibly helpful pharmacist.

Our pharmacist advocated for us with our primary insurance when they denied us a refill of one of Tom's glaucoma eye drops recently. Our primary insurance suddenly thought that a 30 days supply should last 45 days and wouldn't give us a refill.  Giving eye drops to a toddler is not like giving eye drops to an adult! Sometimes you miss on a squirmy little guy or he wipes it away so you give him one more. Our pharmacist told the insurance company, "You realize these drops are for a toddler, right?"

Of course, if his pressure goes up that means an EUA and possible surgery which costs a hell of a lot more than drops! Penny wise and pound foolish as the saying goes... But we got the drops at no cost. I don't even know how but the pharmacist just said come pick them up, I'll take care of it. How wonderful is that? I want to thank him but I also don't want to get him in trouble so I think I will just write him a little thank you note.

So that's where we are right now. We are still fighting these insurance battles but we are very lucky to have excellent coverage. I don't know where we would be without it.

*EUA = exam under anesthesia