AboutTricia Expertise Has your medical insurance company denied your claim and refuses to pay? Have
you received a pre-authorization and still your insurance company
refuses to pay? How can you get your insurance company to reverse a
denied claim? How do you get a provider to waive your copayment if you
are financially unable to pay? Can a provider sue you for a unpaid bill and
will they? Can a provider send me to a collection agency for a medical bill?
If my insurance company does not pay, am I responsible? If you have these questions or others on why your insurance company is not paying your bills, I can help. I can give you "tricks of the trade" to get your insurance company to pay.
I have limited knowledge on Medicare and Medicaid and that is not my expertise. Each state is very different regarding Medicare and Medicaid so you need to review their website when you have questions. So please no Medicare or Medicaid questions!!
Experience In the medical field for over 20 years spending majority of time in the collections aspect.
Question On August 26, 2008 I had out patient surgery to remove a pilonidal cyst. On August 18th I had dropped off my FMLA paperwork to be completed by the surgeon's office and asked them if everything was set for my surgery and had they obtained approval from Aetna, they told me you are all set. I went to my pre-op appointment at the hospital and paid my co-payment for out patient surgery, at no point did anyone mention there was no authorization. In October 2008 I received a bill from the hospital, I called the surgeon's office and told them about they bill. They stated that the insurance company was slow to pay the hospital and that eventually the payment would catch up so I should disregard the bill. I did not receive anything else from the hospital until now 8 months later I received a bill for $4.452.25. I called the hospital and they claim that my surgeon never obtain authorization to complete my surgery and Aetna has told them I am responsible for this balance. I have "Aetna Select" which is an HMO. What recourse do I have in this situation with Aetna and/or my surgeon? How am I to know they did not obtain authorization when I specifically asked and was told Yes, you are all set? Please help!
Answer Hi Angie!
I would first call Aetna yourself because usually under an HMO plan the provider/Dr is required to get authorization prior to any service and if they do not then the patient is not liable. So before doing anything call Aetna and ask. If you are not liable, then all you need to do is send the bill back to the hospital with a note that per Aetna you are not liable and that should be it.
If you are liable per Aetna (never go with the word of a provider) then you need to see if the hospital can do a retroactive authorization which means do one now for back services. It happens but not to often but worth a shot if you are liable. If that does not work then appeal with Aetna and explain what happened.
