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About Tricia
(Top Expert on this page)

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? What are fee schedules and are you responsible to pay them? 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.

Experience
In the medical field for over 18 years spending majority of time in the collections aspect.

You are here: Experts > Industry > Health Plan > Medicare, Medicaid, Insurance, HMO problems

Questions Answered By Expert Tricia
In Category Medicare, Medicaid, Insurance, HMO problems

Subject	Date Asked

Dental problems	9/3/2008
Q: I have teeth that I need to have pulled, and I can not seem to find an oral surgeon where I live ... A: Call Medicaid directly and ask them if they can help you. If they can not find a local one or ...
inheritance question	9/2/2008
Q: my sister recently passed away and has 31,000 retro social sec money going into an estate account i ... A: That question is more a legal question and I really do not have the knowledge to answer it 100% ...
Help with unpaid claim	9/2/2008
Q: Back in September 2007, I was diagnosed with periodontal disease. At that time, I had dental ... A: When you are under the Cobra plan with an employer, if they change their insurance company (usually ...
tummy tuck	9/1/2008
Q: i am wondering i have cigna it is a ppo do you think that they will cover a tummy tuck procedure? A: I doubt it very much----insurance companies only have to pay for procedures that are deemed ...
coded wrong	9/1/2008
Q: I have PCOS-Polycystic Ovarian Syndrome. I recently had some blood work done concerning that. I got ... A: As long as it was denied you can do an appeal however you need to have the proper code to do ...
pre-existing conditions	8/31/2008
Q: I was recently terminated on a job for which my employer would not give me a reason. I had been ... A: Most states allow continued health benefits under Cobra allowing you to have continuous coverage as ...
Medicare part B and HMO	8/30/2008
Q: I am 59 years old and in 1997 I was eligible for Medicare part B because I went on SSDI. I elected ... A: Yes they can require you to sign up for Medicare----------under SSDI/SSI after 24 months you are ...
medical billing	8/29/2008
Q: but apparently maxed out the benefits prior to my last four visits of the year - Nov and Dec - in ... A: If your benefits have maxed out, you are liable for the billed amount not the reduced fee. ...
health coverage	8/29/2008
Q: i am a county employee of nc and i was wondering i have cigna health ins.they have a wellness ... A: You need to find out why they do not cover the lapp band-----is it an exclusion in your policy or do ...
how to get medical treatment for spouse	8/28/2008
Q: my husband was DX with PAD (peripheral vascular disease) have had several admits to hospitals, ICU ... A: You are sort of caught up in the insurance web--------you make to much to apply for Medicaid and not ...
birthday rule	8/27/2008
Q: My friend just recently went back to work. When she went back to work, she and her husband decided ... A: Usually if the primary won't pay the secondary will. So they should submit all the bills to hers ...
HMO denies SNF for no prior authorization.	8/27/2008
Q: When an HMO denies a Skilled Nursing Facility for no prior authorization, what recourse does the SNF ... A: If an insurance requires an authorization and none is done, then they do not have to pay. However ...
Billed 1.5yrs later for MRI	8/26/2008
Q: I just received a notice from my insurance company that the company that did my MRI back in May 2007 ... A: I would not pay it and hold the provider responsible for not submitting the claim in time. ...
ERISA	8/26/2008
Q: I am aware a consumer can file a complaint against an insurance company with the state department of ... A: I am not sure------------I do not think so but if you exhausted all avenues with your insurance ...
pre-approval for birth center	8/26/2008
Q: I would like to use a birth center for the upcoming delivery of my baby. However, Cigna does not ... A: The only thing you can try is to do an pre-approval appeal and use the excuse that there are no ...
I HAVE TRIED SEVERAL TIMES	8/25/2008
Q: I AM LOOKING FOR A LIST OF DOCTORS THAT TAKE MEDICAID I AM LOOKING FOR DERMATOLIGIST BUT I CAN TAKE ... A: You need to go on the Medicaid site for your state and look under provider list.......or call local ...
sleeve gastrectomy	8/23/2008
Q: My weight is 315 and I would like to have a sleeve gastrectomy, but my insurance denial is my ... A: You need to find the exact denial and prove it wrong for the insurance company to pay. If it was ...
Medicare / Medicaid	8/21/2008
Q: Tricia, I have a question regarding when we file a claim through medicare for an exam, the eob comes ... A: You can only charge the amount shown on the eob as patient responsibility. The copay/coinsurance is ...
Ethical Issue?	8/21/2008
Q: I hope you can help me. I've been receiving treatment from a PT for a few months now for foot ... A: Yes your PT can charge you a different rate than they accept from an insurance company that is in ...
Hospital	8/18/2008
Q: I had an emergency room visit for a condition that is not covered by my insurance provider for two ... A: Usually contractual rates are confidential and that information is not given out. Contract does not ...
write off's	8/18/2008
Q: Tricia, on the other end of your spectrum? Can a provider write off the write offs (loss) that are ... A: If you are speaking of fee schedules and/or contract adjustments then you should really do them as ...
primary care provider says.. NO	8/18/2008
Q: I have Blue Cross/Blue Shield I live in the South suburbs of Chicago and my insurance will cover all ... A: Each insurance company has it's own guidelines and you must meet them before they will pay. Find ...
Adjustments on 2ndry insurance	8/15/2008
Q: When billing insurance companies for services are we supposed to take the adjustments on the 2nd ... A: It depends if you have a contract with the insurance carrier......usually most insurance companies ...
impacted wisdom teeth extraction	8/13/2008
Q: My dentist asked me to have my son's wisdom teeth extracted by an oral surgeon because they are ... A: I would call the Oral surgeon's office and ask them why they misinformed you regarding your ...
DEAD BEAT PATIENTS	8/12/2008
Q: I have been reading many of your answers. It seems you always want the doctor/pharmacist to be ... A: Perhaps get the patient to pay their copay up front. We do this now at our company and our ...
Gastric Bypass	8/12/2008
Q: I have Buckeye/Medicaid through the state of Ohio. I called and member services told me that if the ... A: Since the surgery is based on medical necessary, your Dr's office would be the best to address this ...
Medicare Advantage	8/11/2008
Q: A relative is enrolled in Secure Horizon's HMO in Dallas TX (Medicare Advantage). She was ... A: Medicare is only the insurance carrier.....the patient and family should make that decision. They ...
Are my dentist's insurance billing practices illegal?	8/9/2008
Q: I really liked my dentist's office because I never had to pay for anything up front. This dentist ... A: If your dentist participates with an insurance company, he/she does not determine your copayment the ...
Tubal Reversal	8/8/2008
Q: I have harvard Pilgrim Health Care Insurance. and i woukld like to know is there any way to get to ... A: You would have to call them directly and ask them-------each policy is different and only they could ...
bc/bs hmo and ex-employer	8/8/2008
Q: On July 12, 2007 my employer let me go. I wanted to continue my medical and I have been paying my ... A: Not usually------most states allow Cobra for 12 - 18 months and up to 2 years if you are disabled. ...
copays	8/5/2008
Q: My doctor's office has a sign in the waiting room that if you don't have your copay for that visit, ... A: Not sure if this is legal or illegal--------does not seem right to me but I know as a provider you ...
medicare/ workmans comp settlement	8/5/2008
Q: My brother is on disability due to cancer. He has just received a settlement for a workmans ... A: Each of his coverage would have different guidelines........food stamps have very strict guidelines ...
Insurance Coverage/Appeals	8/3/2008
Q: My girlfriend recently had a surgery to remove a metal plate from her arm, which she suffered the ... A: Usually the Dr's office is aware of a patient's insurance and they usually make an effort to stay ...
gap coverage	8/1/2008
Q: In Connecticut, my husband has medicare and health net ruby for perscription coverage, which has ... A: Perhaps check with Health Net to see if you can ungrade your prescription plan. That may be an ...
Non-Medicaid Provider	8/1/2008
Q: I am a non-medicaid provider. I wanted to know if my patient has medicare as his/her primary and ... A: Yes you can as long as Medicare pays as primary. To be fair just advise patient at time of service ...
dentures/ on medicade/care facility responsiblity	7/30/2008
Q: 93 yr old female on medicaid for 3 yrs. In a SC facility that has accepted her only asset SS for ... A: I have no clue--------this is more a legal issue than a medical question. I would assume that the ...
Medicaid/moving!	7/30/2008
Q: I have medicaid and SSI, I will be moving from Ga to Pa in sept. My card says Ga Medicaid, and I've ... A: Since you still have a month or so I would start the process now. Call Medicaid and advise them that ...
medicaid	7/29/2008
Q: I have medicaid but for the first time am about to qualify for health insurance from my employer. Is ... A: I think it depends how many hours you are working, how much money you are making and what type of ...
Cystic Fibrosis	7/29/2008
Q: Ok, I am in a tough place in my life right now. I am a 20 year old female who has had Cystic ... A: Alot of states are now opening up health insurance for non students if their parent(s) have health ...
reversal?	7/28/2008
Q: My wife and I were married on Oct 18 of last year she already had 3 kids from previous relationships ... A: No Medicaid will not pay for a reversal. Medicaid is a health insurance that pays for only ...
Medicare Primary or Secondary	7/28/2008
Q: I am diabled and have been on medicare since 1994. I am also covered as a dependent on my husband's ... A: You need to find out how Medicare classifies you whether they are your primary or secondary. Alot ...
About HMO and PPO PLAN	7/27/2008
Q: I don't known what is HMO and PPO plan. Shall you please explain it. Regards, Rizwan A: Most HMO plans require patients to pick a Primary Dr who sort of manages the patients health needs. ...
Are Benefits received on permanent disability viewed as debt by the Government	7/26/2008
Q: State of: California. Can SSI/SSDI/Medicare/Medical/Hud Section 8 - look for repayments of ... A: Each government plan has different rules and guidelines and unfortunately I do not know what they ...
Daughter has MS	7/26/2008
Q: My Daughter has MS she is eighteen and she is on my insurance through my work BlueCross Blueshield I ... A: All insurance plans are different...it depends on the policy. Some policies have exclusions for ...
moving to new state with medicaid	7/25/2008
Q: who can i contact - i have talked with my case worker she does not know , i want to move closer to ... A: You need to call Medicaid directly-----Florida's Medicaid program...they will tell you how you can ...
Tubal Reversal	7/25/2008
Q: I am a 32 year old disabled female who had a tubal ligation performed eight years ago due to a few ... A: I doubt they will but I would still ask them since each case is unique. Call Medicare directly and ...
BCBSAZ?	7/25/2008
Q: I live in AZ and my husband just got a new job. The company goes through Blue Cross Blue Shield PPO ... A: I think they have a website that may help you however usually you need to wait to find out your ...
bariatric surgery	7/25/2008
Q: I have Blue cross BS state health benefit plan HMO, and they have put the exclusion in their plan ... A: Exclusions in your policy are telling you up front they will not cover certain procedure and they do ...
facility	7/23/2008
Q: if we added new facility to our medicare account and deleted the old facility at the same date. can ... A: I depends-----------if you have old billing prior to that date, you are still authorized by Medicare ...
medicaid	7/22/2008
Q: i have congestive heart failure and did not know mediaid allows me 24 visits a year an i use them ... A: Usually it is something that your DR has to do. He has to prove that it is medically warranted for ...
Dental coverage thru Medicare/Medicaid	7/21/2008
Q: I am trying to help my grandmother (95 years old) have some much needed dental work done (surgical ... A: Here is the website for Medicare with the information you need-- ...
Wheelchair questions	7/20/2008
Q: My grandmother is having a hard time getting around and I want to help her to get a hoveround or ... A: The best thing to do is to call a local provider who sells them and ask if they could help you get a ...
Medicaid on hold	7/20/2008
Q: Last march I applied for medicaid for my family (me, my wife and baby). After submitting all the ... A: The only way to get your application on top for processing is to call every day to ask them if you ...
Insurance will not pay claim	7/19/2008
Q: I had surgery last year. Prior to the surgery, the surgeon's office handled the insurance and sought ... A: If your surgeon has a contract with your insurance company that requires prior authorization then ...
insurance bills me saying they paid when shouldnt have	7/18/2008
Q: My wife canceled our Blue Care Network (BCN) insurance and went to Priority Health. The paperwork ... A: The hospital was the one who billed BCN not you so sort of surprised they would go after you. The ...
trying to get medicine	7/14/2008
Q: yes my sister is here visting from la she have an health network card from la we are trying to get ... A: I would suggest for her to call her insurance company and ask them. They may not allow out of state ...
Physician bills me for	7/14/2008
Q: Medicare paid the 80% of approved amount of office visit fee and balance of claim was originally ... A: I think the info you found states that the Dr is going against their contract with Medicare. I ...
need help with gastric bypass	7/14/2008
Q: i wanted to know if it is a insurance that i can purchase to help me get a gastric bypass done my ... A: Most insurance companies do not pay for gastric bypass and then ones that do require patients to ...
Physician bills me for "service fee"	7/13/2008
Q: Medicare paid the 80% of approved amount of office visit fee and balance of claim was originally ... A: The only amount you are liable for is the amount on the Explanation of benefits that Medicare sends ...
how do i find a doctor who accepts my insurane	7/13/2008
Q: how do i find a doctor who accepts my insurance. The adult medical waiver program from lapeer, ... A: I am not familiar with your insurance company however there is usually a website for all government ...
MEDICAL BILLING	7/9/2008
Q: I NOTICED WITH SOME INSURANCES IF A PATIENT GETS A PREVENTIVE VACCINE OTHER THAN AT THEIR ANNUAL ... A: All insurance companies and policies are different...there would be no way to make a guess on what ...
madicaid	7/9/2008
Q: I have medicaid and have recently found out that due to a tubal ligation that i had done after the ... A: They usually will not pay for the reversal, however you can try to get them to authorize it due to ...
coverage changed mid year	7/8/2008
Q: My insurance coverage changed mid year. Do I have to meet deductibles again? I live in New Jersey. ... A: Not usually but some may require you to start their calendar year...I would call Cigna and ask them. ...
MEDICAID BENEFITS/SSI BENEFITS	7/7/2008
Q: SOME TIME BACK MY FATHERS SSI BENEFITS WERE STOPED BECAUSE IT WAS STATED MY MOTHERS INCOME WAS ... A: You need to call SSI to discuss your father's case directly---I can not give you their number since ...
Does Keystone Mercy cover Lapband?	7/7/2008
Q: I am interested in the lapband procedure... I am on medicaid (Keystone Mercy) I live in Philadelphia ... A: Yes they do pay if it is medically necessary and you meet all their guidelines. What I would ...
Continuing coverage for 19 year old	7/4/2008
Q: Blue Cross has just sent me a letter saying I failed to provide a letter from my son's college ... A: I would call Blue Cross directly and speak to a manager there and explain your case. I would think ...
POST OP COPAYMENTS	7/2/2008
Q: OUR PRACTICE IS CAPITATED WITH CERTAIN HMO/MEDICAL GROUPS AND WOULD LIKE TO KNOW WHERE CAN I FIND ... A: Unsure what insurance company you are speaking of. My company deals with DME and we use the ...
sitters/home care	7/2/2008
Q: BLUE CROSS PROVIDES $40.00/DAY FOR HOME HEALTH CARE. HOW DO I APPLY FOR THAT? THEY SAID TO CONTACT ... A: Unsure what you are speaking of. Do you currently have Blue Cross Insurance? Each Blue Cross plan ...
Billing Auto/Work Comp Massage Therapy In PA	7/1/2008
Q: You've been so kind in assisting me in the past and I've come across another question posed to me by ... A: Found this article on the Internet-------looks like ok to bill auto and w/c using this code........I ...
Claim for carpal tunnel surgery denied	7/1/2008
Q: United Healthcare has denied a claim(s) for carpal tunnel surgery that I recently had. I am a ... A: Any time you have surgery you need to get it preapproved if possible to ensure that your insurance ...
Prescription Denial	6/17/2008
Q: My Dr. (Dr. Sponaugle,expert in his field and well known & trusted) has prescribed some medications ... A: Yes your insurance company is able to deny a RX if they feel it is not medically necessary by their ...
Medicaid and Dental work!	6/15/2008
Q: One needs to be taken out, Because it have broken off half the way. The other is starting with a ... A: For under age, yes. States differ. Some states offer it for adults, but it may only be for ...
adjustment to jaw through medicaid	6/14/2008
Q: medicare does not cover dental, however, adjustment to jaws, etc. may be covered. Does CT medicaid ... A: Usually Medicaid follows Medicare's guidelines for the most part. If you can prove that your TMJ is ...
Out of network charges	6/13/2008
Q: I was having my ultrasounds at the Maternal Fetal group at the hospital for my pregancy when I had ... A: You can always try. Call the Dr up and state that it was implied to you that he was in your network ...
Insurance Claim Denied - What am I liable for?	6/9/2008
Q: I recently had a doctor-referred MRI done after suffering a knee injury playing rugby w/ the ... A: If your insurance denies the claim than the PPO discount is not valid thus you owe the amount ...
insurance won't pay after authorizing & dental work completed	6/8/2008
Q: I specifically provided the dental firm billing rep w/all the pertinent insurance info & stated work ... A: Being that your account is already with a collection agency, usually after many attempts to get paid ...
insurance won't pay after authorizing & dental work completed	6/7/2008
Q: I specifically provided the dental firm billing rep w/all the pertinent insurance info & stated work ... A: You have to call the dental office and work something out with them. It probably is to late to try ...
Aetna Insurance Denial	6/5/2008
Q: I have been denied part of my surgery by Aetna Insurance. Dr. Larry in Dallas, Texas has diagnosed ... A: With most insurance you can only usually appeal twice then after that they won't even look at your ...
Reimbursement	5/29/2008
Q: My husband had some dental work done in mid-March. He paid for the services in full and has his ... A: Most providers/Dr's just take their time to pay back overpayments. It is very common to wait until ...
Prepare for denial	5/29/2008
Q: My doctor's secretary told me Monday to check into the hospital for a 5-day IVIg treatment. On ... A: I am assuming you went into the hospital for 5 days for this treatment so the denial from your ...
chiropractor and health plan	5/29/2008
Q: I started going to the chiropractor b/c i had a free coupon for a free exam.. i started going for ... A: As a courtesy yes the chiropractor should have told you that they were not in the network however it ...
HMO TriWest Prime / formerly Champus	5/28/2008
Q: I have TriWest Prime it's an HMO thur the Military formerly Champus. Can you tell me if they pay for ... A: I am pretty sure they will pay for a lap band but I think they have certain requirements prior. ...
referral	5/28/2008
Q: My fiance was send by her physician for a regular mammography to the Breast Cancer Institute. Her ... A: I think I would call the place where she got the biopsy and ask them if they could help get you a ...
ind. med. ins. w/pre-existing conditions	5/27/2008
Q: need to buy health insurance 29yr old fem/smoking, pre-existing cond--endrometriosis and autoimmune ... A: Start with the bigger insurance companies such as Aetna, UnitedHealthcare and Blue Cross Blue Shield ...
is my sons medicaid still active	5/24/2008
Q: I was recently applying for medicaid for me, my son was already receiving it but when I applied they ... A: If that is what the letter says than it may be so. However I would call Medicaid and ask them if ...
Medicaid beneficiary	5/22/2008
Q: When my son was first born he and I was both on medicaid. He stayed on medicaid for a year, April ... A: Yes you will need to appeal and may have to prove that you have been trying to get these bills paid ...
BCBS HMO	5/16/2008
Q: I work for a social worker who is part of BCBS of Massachusetts but not the HMO Blue network - that ... A: Very hard to get on a closed HMO network------you can continue to call to see if they have an ...
BCBS HMO	5/15/2008
Q: I work for a social worker who is part of BCBS of Massachusetts but not the HMO Blue network - that ... A: HMO's are very difficult to fight.......they have a network and a patient must stay within the ...
lap band surgery	5/15/2008
Q: what are the rules for medicaid and the lapband surgery A: Medicaid does not cover obesity.....so they will probably not cover the lapband surgery. Just to be ...
Insurance denies claim	5/14/2008
Q: I had an accident while vacationing in a new city and had to get stitches. We ended up in ER but due ... A: I think BC should take the "bullet" and pay the Urgent care center as an exception which they do all ...
co-payment question	5/12/2008
Q: is there somewhere in print, that I can show my physician that it is illegal to w/o co-payments. He ... A: See website address for complete information-------- "Physicians should be aware that forgiveness ...
prescription copay: a contract?	5/12/2008
Q: after charging me a copay and letting me walk out the door, and therefore taking the medicine i got, ... A: Legally you are responsible for any bills your insurance company does not pay. However you would ...
Billing co-insurance at the time of service	5/8/2008
Q: and thank you for your reply to a question I submitted yesterday. I've got one last inquiry! The ... A: If you know what the patient's copay should be, you are allowed to collect that amount and if for ...
Billing Patients After IME	5/7/2008
Q: I'm billing for a chiropractic office in PA. I wish to ask if it is legal to bill a patient (who ... A: If a patient has auto insurance and their auto insurance will not pay, you can then bill the ...
insurance and batreatic bypass	5/6/2008
Q: I have United Healthcare Ins. and they refuse to pay for surgery even if it is a medical necessity. ... A: You need to find out the exact denial and appeal that decision. Many insurance companies require ...
medicaid	5/5/2008
Q: what is the best way for following up Medicaid payments. because they owe us. two cases: if medicaid ... A: Call them directly----------give at least 45 days to 60 days for payment and if not paid call them ...
past bills	5/1/2008
Q: Ok here goes, my medicaid was stopped, after many fair hearings it was given back to me. I am being ... A: Yes-------I would call the provider and advise them to rebill Medicaid and ask them to refund your ...
past bills	5/1/2008
Q: Ok here goes, my medicaid was stopped, after many fair hearings it was given back to me. I am being ... A: It depends on why your Medicaid was stopped......if it was in error, then yes they should pay for it ...
Tubal reversal	4/30/2008
Q: please any info will be a big help!!! thanks so much in advance A: They will not pay for this. Reversal is not always successful. Most private insurances do not ...
bill	4/27/2008
Q: can i send statement to a patient if his secondary insurance did not send EOB after one year but his ... A: If the Dr has a contract let's say with Aetna and in that contract it states that a provider must ...
bill	4/27/2008
Q: can i send statement to a patient if his secondary insurance did not send EOB after one year but his ... A: Yes you can bill a patient for any balance unpaid. Some contracts though state that you must bill a ...
Denied Coverage for Breast Reduction	4/27/2008
Q: I'm a 31 year old female that is experiencing severe back and shoulder pain, tension headaches and ... A: I am assuming they denied the procedure due to lack of medical necessity. If this is the case you ...
Insurance Co claims they paid, Doctor claims they didn't	4/25/2008
Q: I am writing for my father as he has very poor eyesight and can't see well enough to do so himself. ... A: What you need to do is to get an explanation of benefits also known as "EOB" from your insurance ...
Adjustable Gastric Band Surgery Coding	4/24/2008
Q: I'm trying to find out how to code an Adjustable Gastric Band outpatient surgery. I know that 43770 ... A: I am not sure-----what I would suggest is to call the insurance company you are billing and ask them ...
medicaid & medicare prescription copay	4/22/2008
Q: a close friend of mine has MS along with numerous other health issues. she is insured by both ... A: Every state is different and has different Medicaid programs. Most states do require a small copay ...
Medicaid	4/10/2008
Q: My aunt was recently in a terrible car accident and now she needs a primary physician..I need a list ... A: You need to call Medicaid directly and ask them. Their phone number should be on the card. There a ...
Ambulance Bill	4/9/2008
Q: I was taken to the E.R from my job to the hospital by ambulance I have Blue Cross Blue Sheild PPO.My ... A: Yes you can always appeal any denial. Usually during an emergency situation going out of the network ...
Denial by insurance to pay	4/9/2008
Q: My insurance denies paying for lapband surgery even for medical reasons. Is there anyway or anyone ... A: It depends why your insurance company is denying the surgery. If it is an exclusion in your policy ...
Medicare supplement Human ppo denied payment of my hospital bills	4/8/2008
Q: I had a colonoscopy followed ny a hemorrhoidectomy for rectal bleeding on 3/6/08. I have medicare A ... A: You have to find out why they denied your bill. Usually it is due to needing medical paperwork or ...
TMJ	4/2/2008
Q: My daughter has severe TMJ that has been diagnosed by several dentist's, oral surgeons and ENT's. ... A: Why will Great West not pay? If it is on their non covered list, then they do not have to. However ...
Medicare and Tubal Reversal	4/1/2008
Q: I have Medicare (due to disability) and I live in the State of South Carolina... I was wondering if ... A: I would not think they would......Medicare only pays for procedures that are medically necessary and ...
insurance cancelation	3/29/2008
Q: i had hip coverage thru mta nyc, my husband died january 31, 2006 and they said i will only be ... A: You can try to call mta and advise them that you had not received any bills but the first which you ...
Medicaid & Primary Insurance	3/27/2008
Q: Father separated from mother, father pays for private insurance carrier through his employment on ... A: It depends what insurance company is the primary carrier........I am assuming that the private ...
Problem with old hospital bill	3/26/2008
Q: My husband had to go to the ER back in 2006.We had Medicaid coverage at the time.I specifically told ... A: You need to get the hospital to close the bill......the hospital is the one who hired the collection ...
Out of Network Coverage	3/25/2008
Q: My mother wants to have an operation done by a surgeon who accepts her insurance (UPMC); however, ... A: The only way an insurance company will pay an out of network hospital is if the operation can not be ...
HMO Low Payment	3/24/2008
Q: My daughter was in the hospital in August of 2007. The bill was almost $1400. I paid the co-pay of ... A: You need to find out what the contract rate is and if it was paid by Oxford. Get Oxford to write ...
insurance disability	3/17/2008
Q: 2nd surgery circumsized because they couldnt because of him having to have emergency surgery at 5 ... A: Each state has different rules for insurance for the disabled. You need to find out what medical ...
HMO denial of claim	3/12/2008
Q: My 8 year old son's dentist (confirmed by two independent orthodontists) has informed us it is ... A: Usually extractions of teeth is not covered by your medical coverage however if you have dental it ...
Durable Medical Equiment	3/10/2008
Q: My mom has to use oxygen (medical necessity). She is also in End Stage Renal Failure. ... A: Attached is some info I found on the Internet regarding Oxygen and Medicare. Hope this helps!! ...
Getting insurance to help pay for gastric surgery	3/5/2008
Q: I am in need of gastric surgery. My health care policy does not cover surgery for obesity or morbid ... A: I think I would call the place where you think you may get it done and ask them. They would know if ...
insurance denial	3/3/2008
Q: my daughter had 4 minimal surgery done,in de funiac springs florida at the micro spine clinic ,her ... A: You can always appeal the denial for Aetna......unsure of the reason for the denial but if you can ...
my sick mother	3/3/2008
Q: My mother has 4 brain aneurysms and has no health insurance coverage, she is on social security ... A: How long has your mom been on disability? After 24 months in most states you are eligible for ...
Speech Therapy	3/2/2008
Q: Greetings! My husband works for the Post Office and each year in December we are able to select ... A: For some strange reason most insurance policies have many exclusions on speech therapy......not sure ...
I need help!	2/29/2008
Q: I am 19yrs old and I have Juvenile Papillomas. I have been having microlaryngoscopic surgery every 6 ... A: Look into Charity care in your state, usually it is associated with hospital care/surgery. And if ...
TM - Denied Health Insurance	2/25/2008
Q: I had health insurance through my college up until January of 2007 (or December 2006, I don't ... A: The insurance commission office would probably be able to give you information you need. Usually ...
Denial of Claim	2/23/2008
Q: While I had Humana PPO, I became nauseated for about three days. More so on the fourth day. I took ... A: Humana is denying the claim due to not being an emergency.....so all you have to do to reverse this ...
insurance	2/22/2008
Q: ive been denied health insurance, due to hydrocephalus. which i just found out that i had in dec of ... A: I would call Medicaid and tell them that you need to see a neurologist surgeon however can not find ...
TM - Denied Health Insurance	2/21/2008
Q: I had health insurance through my college up until January of 2007 (or December 2006, I don't ... A: Alot of insurance companies now do not have a pre-existing clause but many still. If an insurance ...
Out of State Service - Medicaid Denying Payment	2/20/2008
Q: Daughter went to ER in Kentucky 12/2006. She was, at that time, covered by Florida Medicaid. KY ... A: ! The only way to get this debt off the credit reports is to have Medicaid pay. You can reverse ...
explanation code	2/13/2008
Q: My husband went to see his urologist on January 8th and we received a statement from our health ... A: Usually at the end of the explanation of benefits it gives you the explanation of all codes used, it ...
coordination of bcbs hmo insurance copay	2/13/2008
Q: i subscribed to bcbs hmo medical insurance plan through my ex employer, from where i resigned in ... A: I am not real clear on the issue........it seems to me that you are saying that you had a policy ...
emergency room billing by hospitalist physician unbundling	2/12/2008
Q: can the e.r. doc and the hospitalist for services performed int he e.r. each bill for interpretation ... A: Usually the Dr who reads any tests can charge. When you are in the hospital every Dr can charge for ...
UHC refuses to send denial letter.	2/10/2008
Q: Tricia, In October of 2007 I started the process of getting a lapband procedure approved. The ... A: If you Dr was trying to get the surgery authorized then that office would probably receive the ...
appealing a claim	2/7/2008
Q: I had gallstones removed about 1 1/2 years ago. I received a bill last month from the hospital for ... A: Did you get the surgery approved? And what code did they use then? I would ask for a copy of all ...
procedure performed without preauthorization	2/5/2008
Q: My wife recently had a minor outpatient procedure performed by her doctor. Prior to having the ... A: Not all insurance companies require preauthorizations for all procedures. Many are based on medical ...
lap band	2/4/2008
Q: i have been trying for the last 4 years to get a weight loss surgery done i lived in KY, my doctor ... A: You need to find out what requirements your new insurance company has for this surgery then meet ...
hip replacment and humana ppo	2/3/2008
Q: I have to have a replacement one side, what will my out of pocket expenses be? no one can give me ... A: It depends on what the charges are--------I am assuming you have Humana Medicare program, so if you ...
Pre Existing condition health provider refuses to pay	1/28/2008
Q: I was recently laid off from my job last October 07 and I had insurance with Blue Cross blue shield ... A: I would carefully check out your policy...most insurance companies will not use the pre existing ...
ppo and non-provider	1/25/2008
Q: In 6/07, my husband was hospitalized for a week and then needed home treatment of iv infusions. The ... A: I would call Walgreens and tell them that the hospital made a mistake and advised you that they were ...
Medicare vs. health plan	1/25/2008
Q: I am 67; have medicare A&B; have BCBC of S.C. as provider. Medicare is primary. BCBC was primary ... A: I would suggest to go on to Medicare's website, www.medicare.gov and view the prescription portion. ...
Health insurance for son	1/16/2008
Q: My son recently turned 23 and is no longer eligible for coverage under our group plan which he was ... A: Some states allow parents who have health insurance to cover their children up to age 30 ...
Blue cross Blue shiel card	1/14/2008
Q: Does BCBS card covers also the discounts on medicines when outside the country? My retired us ... A: Some Medicare Advantage plans may provide worldwide coverage benefits for health care needs when you ...
g/bypass - when do I claim?	1/11/2008
Q: I am using a health insurance broker to get the coverage and she has confirmed that they will cover ... A: It is hard to say since every policy is different.......and having a gastric bypass surgery is for a ...
billing issues	1/9/2008
Q: in mid 2005 I had stomach surgery, I paid the deductible and fees that I received bills for. Now in ... A: I would contact your insurance company and ask them for the explanation of benefits for this ...
testing	1/8/2008
Q: I have undergone a considerable number of tests (which have been "inconclusive" or "don't look ... A: You can appeal with your insurance company. If these test were inconclusive then you may have a ...
ANESTHESIOLOGIST FAILED TO OBTAIN PREAUTHORIZATION	1/6/2008
Q: I'M IN DESPERATE NEED OF ADVICE.ON 11/7/2006 MY HUSBAND WAS RUSHED TO THE ER BECAUSE OF STOMACH ... A: You need to call the hospital and ask them why they did not get pre approval from your HMO for the ...
Mississippi Chips and Hemangioma Is it considered Plastic Surgery	1/6/2008
Q: Tricia I was hoping to find out what I can do if anything, my daughter was born with a ... A: Most medical plans do not pay for Plastic surgery. Procedures need to be medically necessary for an ...
Secondary insurance to traditional medicare	12/19/2007
Q: I HOPE YOU CAN HELP! NEITHER MEDICARE NOR MEDICAID CAN...EVERYONE YOU SPEAK TO HAS A DIFFERENT ... A: Your state Medicaid office would have that answer.......I am not sure since all states are ...
MEDICAID AS SECONDARY	12/14/2007
Q: MY DAUGHTER HAS MEDICAID AS SECONDARY INSURANCE AND I COVER HER UNDER MY OXFORD PRIMARY THE DOCTORS ... A: There are many plans under Medicaid, so depending on your plan. I would call Medicaid directly ...
Insurance Co. run around	12/5/2007
Q: I am writing for a lady whose mother was in a nursing home for quite a while before her death in ... A: Even though her benefits expired, most providers will still bill them for the denial so that you can ...
surgeon failed to get pre-approval/ins won't pay	12/5/2007
Q: I had non-elective surgery a couple months ago after all other means of treatment failed. Under my ... A: If your surgeon did not obtained authorization than that is his fault not yours. If your PPO ...
Insurance Co. run around	12/5/2007
Q: I am writing for a lady whose mother was in a nursing home for quite a while before her death in ... A: I think you need to clarify with UnitedHealthcare what exactly they are looking for. Whether a ...
medicare	12/5/2007
Q: When I signed up for social security and medicare did I sign up under contract law? Thank You,Dean ... A: Medicare is a governmental medical insurance for the elderly or disable. They have a set policy and ...
Incorrect Bill	12/4/2007
Q: My husband was in clinical trials for cancer for 3 years. Recently he was told the treatment ... A: It seems to me as though you covered yourself so I would definitely call and find out where this ...
Health Ins	12/4/2007
Q: I currently have Anthem-Matthew Thorton Blue through the company that I work for. I've been at the ... A: Usually if you are laid off or fired, your insurance is usually active for another 30 days. Most ...
Out of Network	12/2/2007
Q: I went to a doctor from my insurance list, and I was told that a PA would see me since the doctor ... A: I would insist that they bill correctly and don't take no as an answer.......tell them that you will ...
Out of Network	12/2/2007
Q: I went to a doctor from my insurance list, and I was told that a PA would see me since the doctor ... A: I would call the Dr's office and advise them that you saw the PA who was in your network and demand ...
ER visit	11/29/2007
Q: I had to take my friend to the ER recently due to a concussion. He had horrible short-term memory ... A: Sometimes hospitals have programs for people without insurance........have your friend call the ...
uninsured motorist	11/28/2007
Q: My wife was hit by an uninsured motorist. Had surgery and things are greatly improving. We have Blue ... A: By having more coverage you protect yourself................remember your health insurance may not ...
uninsured motorist	11/28/2007
Q: My wife was hit by an uninsured motorist. Had surgery and things are greatly improving. We have Blue ... A: When involved in a car accident in most states, your auto insurance is your primary........meaning ...
Professional Courtesy	11/27/2007
Q: A physician who was treated in a hospital emergency department by an emergency physician is asking ... A: Attached is some info from the Internet that I found regarding this..... Professional Courtesy ...
Error made by Gov't---New appeal being offered for Medicaid	11/25/2007
Q: ..My friend applied for both Medicaid and Disability back in 2005 (He has an inoperable brain tumor) ... A: I would think so if the disability denial was based on the same reason. I would tell him to call ...
Billing by Anesthesiologist very late	11/22/2007
Q: My daughters out patient surgery was pre-approved by her HMO. 8 months later she gets a bill from ... A: If the HMO denied the claim due to not being billed in a timely manner, then yes it is the fault of ...
Billed for Doctor's mistake	11/16/2007
Q: I had a breast complex cyst aspiration in Dec 2006. The Dr radiologist aspirated the wrong cyst (a ... A: A lawyer would probably charge you more than the bill is. You need to work with the hospital since ...
insurer approved then reversed	11/14/2007
Q: I had knee surgery almost two years ago. BCBS approved coverage for a knee brace after surgery. I ... A: I would suggest to get an approval in writing with an authorization number. Again this still may ...
Lap Band	11/14/2007
Q: I work for the state and Employees Retirement System dictates what Blue Cross/Blue Shield will ... A: I think I would send them a list of all the insurance carriers who know pay for lap band surgery. ...
Lap band surgery	11/11/2007
Q: Will Missouri medicaid pay for lap band surgery in any situation? I need to lose over 100 pounds, ... A: Medicaid does pay for many types of obesity surgery however you must meet certain criteria. Call ...
jaw surgery	11/10/2007
Q: My husband had a jaw defect that required surgery. Just before surgery we found out that he was ... A: It is probably not going to be covered. It is very rare for an insurance company to deny a surgery ...
Medicare Guidelines for Lap Band Surgery	11/6/2007
Q: What are Medicares guidelines for lap band surgery I have a friend that needs to have it, I have ... A: On February 21, 2006, Medicare announced and immediately implemented new rules for the coverage of ...
Medically Necessary and Payment	10/29/2007
Q: I spent 4 days in the ICU last June when a few weeks after minor outpatient surgery, I started ... A: If your plan is a true HMO then the hospital should have gotten a referral in order for them to be ...
Lapband surgery	10/29/2007
Q: does kaiser permanente hospital cover lapband surgery? A: It depends on your specific policy and the state you live in. I would suggest to call your ...
bypass	10/26/2007
Q: im looking for insure. that covers bypass surge. what ones do u know of. i have a BMI of 46.1 and i ... A: All insurance companies are different. They have numerous policies under their main where some do ...
Trouble Getting Claims Paid	10/24/2007
Q: I have Osteoarthritis, and I had arthoscopic surgery on both knees in the year of 2002.This was just ... A: Whowever the insurance carrier was when you had surgery is the company liable for the payment. You ...
lapband	10/22/2007
Q: I would like to know if bluecross blueshield of ga. will pay for a lapband surgery. I work in a ... A: To determine if your insurance policy covers weight loss or bariatric surgery, refer to the ...
Medicaid	10/20/2007
Q: I'm 9 months pregnant and I live in Va. I'm due to deliver any time now. My boyfriend is going to ... A: If you are going just to visit, you probably are. If you are moving there, you would have to become ...
approved then denied after surgery	10/11/2007
Q: About a year ago I had a kidney stone that became lodged in my tract. The doctor gave me the option ... A: Even though the hospital told you that it was pre approved, you as the patient are suppose to follow ...
Wellcare and Medicare	10/8/2007
Q: If I have Medicare and then get Wellcare as a supplemental, if I still go to my specialist who is ... A: I am not to clear on your question but I will try to answer it......... If Medicare is your primary ...
billing problem SOS	10/2/2007
Q: during my pregnancy, i went to the same dr's office twice for sonogram. for the first visiting i ... A: If your EOB from UnitedHealthCare states you have no more responsibility than your $15.00 copay, I ...
Avonex Payment	10/2/2007
Q: We have a patient that wants to come here for her Avonex injections under Part B Medicare. My ... A: You need to know the billing code then look it up on Medicare's website----they have fee schedules ...
Incorrect billing by	9/30/2007
Q: On four occasions over the last 2-3 years, I, or members of my family have received care at an ... A: It makes alot of sense what you are saying.........perhaps call your insurance company directly and ...
collection	9/25/2007
Q: We currently have certain insurance companies that we are contracted with that are not paying ... A: Do you mean billing the patient or send the insurance company to an outside collection agency? Most ...
Benefit denial after being given preauthorization for a bariatric surgery	9/23/2007
Q: I was given verbal confirmation of benefits for a bariatric procedure. My doctor's office was given ... A: The next step is the appeal process......you need to know the specific reason why they denied the ...
MVA settlement and Medicaid	9/21/2007
Q: Avalanche Driver on cell phone backed over my sister, who was thrown off her Hoveround. The ... A: Medicaid will ask to get reimbursed since it was an auto claim not health claim. In an auto claim ...
Medicare and Medicaid	9/20/2007
Q: If I'm a part. provider with MCR, but not MCD...Can I bill pt for the 20% MCR doesn't pay?? I would ... A: If you only participate with Medicare and not Medicaid, then once Medicare pays their portion, you ...
Bill to Medicaid Patient?	9/18/2007
Q: I am in trouble in finding out what patient should get the statement and what patient should not. ... A: Just to clarify this are you saying that Medicare paid their portion then via Medigap program sent ...
Bill to Medicaid Patient?	9/18/2007
Q: I am in trouble in finding out what patient should get the statement and what patient should not. ... A: When Medicaid pays they send an explanation of benefits and on that form, they will show if the ...
tuable ligation reversal	9/7/2007
Q: I had my tubes tied after having my fourth child, had to have an emergency c-section and my baby ... A: It depends on your specific HMO policy. You need to call the Customer Service Department and give ...
NYS Medicaid	9/4/2007
Q: What do you suggest for the new requirements of NY city medicaid concerning being forced to join a ... A: Most HMO plans are with major insurance companies so I doubt that the majority of them will go out ...
My Daughter	9/4/2007
Q: I have Medicaid and Medicare,I'm getting Custody of my 3 year old Girl,will she be Covered by My ... A: Medicaid should definitely pick up your daughter if you are currently on it. You will have to call ...
lap banding	8/28/2007
Q: I was hoping you can answer a question about getting insurance to pay for lap banding. When I ... A: Not really. Every insurance company can "exclude" any type of Rx or procedure. When they exclude ...
hi	8/26/2007
Q: "went to a doc in ny for initial visit doc drew blood and also gave b12 shot and total visti time ... A: Checked Medicare's 2007 fee schedule for the NY area.... 99204 Office/outpatient visit $164.18 ...
hi	8/25/2007
Q: "went to a doc in ny for initial visit doc drew blood and also gave b12 shot and total visti time ... A: I could not tell you what the reimbursement would be since I do not know what code the Doctor used. ...
hi	8/25/2007
Q: "went to a doc in ny for initial visit doc drew blood and also gave b12 shot and total visti time ... A: A Doctor can charge Medicare any reasonable amount they want to however Medicare has a set fee ...
Out-of-state medicaid claim sent to collections	8/23/2007
Q: Tricia, I am legal guardian of twin grand nieces. One is asthmatic. When we vacationed in Alabama, ... A: If the AL hospital is in the Medicaid network then they must bill another states Medicaid program. ...
chemotherapy and hearing damage	8/22/2007
Q: My five year old daughter needs hearing aids. She has hearing damage due to her chemotherapy. Why ... A: BCBS is a tough insurance, probably the toughest.......Unsure why they denied the claim but if it is ...
why they won't pay claim	8/22/2007
Q: my 21 yr. old son have ear lobe surgery for repairmen, on 9-14-06. he receives a letter in july -07 ... A: You need to prove in your appeal that this surgery was not cosmetic but medically necessary. Get a ...
Q.M.B	8/20/2007
Q: I just had total knee replacement. Then went to a nursing facility that I had to leave in 3 hours. ... A: I am unsure what QMB is??? I would call your Social Worker and ask her to help you...tell her ...
breast reduction	8/16/2007
Q: I had a breast reduction 18 years ago with Kaiser. The surgeon did not make me the size I wanted to ... A: I think I would start with Kaiser and do an appeal questioning them and see if they will make some ...
HMO, PPO	8/16/2007
Q: I am trying to get these questions answered in relationg to Florida Statutes. 1. If a health care ... A: With limited space, I will attempt to answer your questions......unsure of some of your questions ...
Medicaid Problem	8/15/2007
Q: I'll try to keep this brief. I obtained medicaid benefits a year ago while in the hospital with no ... A: Usually the Doctor's office calls the insurance company to ensure they will be getting paid. And ...
PPO claim denied	8/12/2007
Q: I have been going to a Bariatric surgeon for the past year and he wants to do a "pannis" removal ... A: Unforunately if UHC has an exclusion in your policy than they are telling you up front that no ...
prexsisting conditions...	8/11/2007
Q: I've had insurance through my company for 3 years now. Last Nov. my company changed insurance ... A: Many insurance companies have clauses regarding preexisting conditions. Check your policy handbook ...
Insurance and prexisting condtiotns	8/11/2007
Q: We started with a new health insurnace thru my husbands employer. They will pay on some medical ... A: Yes many insurance companies require you to have no break in insurance coverage for preexisting ...
Possible denial of Breast reduction surgery	8/10/2007
Q: Reluctantly the Physical Medicine department gave me a referral to plastic surgery to discuss the ... A: I did answer this question but it came back to me again so perhaps my answer did not go ...
Bills sent to Collection Agency	8/8/2007
Q: I remember I asked you a question on May 24, 07 regarding to my mother coming to USA visiting me ... A: You are not legally responsible to pay your mothers medical bills. So what I would do is to write ...
Insurance Coverage - Preexisting Condition	8/6/2007
Q: I just had a Echo-cardiogram done and my insurance company did not cover as it was for a ... A: I would definitely ask the Dr to take the contract rate that BCBS would have paid or accepted. Tell ...
denied	8/3/2007
Q: My virginia medicade sent me a lette denying me of a breast reduction due to: medical documentation ... A: I would call your Doctor's office back and advise them that they need to submit more medical ...
Why now?	8/2/2007
Q: I have never paid for a prescription, today I go to CVS to have a pain reliever filled and am asked ... A: It depends on your insurance company and your individual plan. If you are on Medicare, they do have ...
How do I find out	8/2/2007
Q: How do I find out what type of medicaid I have? And how do I find out if the oral surgery that I ... A: Medicaid is usually specific to your state. So go on line and list Medicaid in "your state". Their ...
Medicaid Bills	8/1/2007
Q: I gave birth to my son about 9 months ago and just now am receiving bills saying that Medicaid ... A: I think you are saying that BCBS was your primary insurance carrier and Medicaid was your secondary ...
Medicaid/Medicare	7/31/2007
Q: I'm hoping that you can lead me in the right direction. I have pulmonary fibrosis, Rheumatoid ... A: Usually most states require you to be on/collecting disability checks for 24 months. In NJ they ...
Medicaid/Medicare	7/31/2007
Q: I'm hoping that you can lead me in the right direction. I have pulmonary fibrosis, Rheumatoid ... A: I would find out if you can do an appeal with Georgia Medicaid explaining why you need to use an out ...
Surgery	7/29/2007
Q: My son needs to have surgery for gynemastia- we have insurance but I know they are going to deny ... A: Insurance companies only pay for procedures that are medical necessary, they do not pay for cosmetic ...
Can Mom's medical billers come to me	7/24/2007
Q: We live in Florida. Mom has lived with my husband and I for over 30 yrs. She is an Alzheimer ... A: This is more a legal question I think but usually if you have the power of attorney, you are able to ...
IN REALLY NEED HELP!	7/19/2007
Q: single,unemployed and discovered about 3 months ago that I am pregnant i think i am currently now 7 ... A: Call Medicaid today and tell them that you need insurance ASAP.....they usually are able to rush it. ...
Provider write-offs in the future	7/18/2007
Q: Tricia, Are you aware of any empirical data that details the percentage of money that private ... A: I think you mean "fee schedules".......this is the amount that if you stay in a network that an ...
Matter of Life and Death	7/16/2007
Q: I have Blue Cross Blue Shield insurance and have called them to see if my plan covered the Lap Band ... A: Exclusions usually can not be appealed.......a few plans may so call your insurance company and ask ...
prostate biopsy	7/14/2007
Q: My husband had a prostate biopsy done in his urologist's office, then he had radiation and seed ... A: Usually insurance companies pay per procedure code so if both the hospital and an office used the ...
Blue Cross	7/14/2007
Q: I will soon have coverage under Blue Cross and was wondering if they will cover gastric bypass ... A: Many Blue Cross's do pay but have some guidelines and requirements. Each Blue Cross Plan is ...
Matter of Life and Death	7/13/2007
Q: I have Blue Cross Blue Shield insurance and have called them to see if my plan covered the Lap Band ... A: First you need to deem if this surgery is an "exclusion" in your plan or that it just needs to be ...
Preauthorized, and still denied claim	7/13/2007
Q: I broke my elbow, and after surgery began physical therapy. Every time I went to PT, I arranged for ... A: Definitely appeal with Aetna.......hopefully you have either something in writing regarding the ...
insurance	7/8/2007
Q: I wanted to know if I have medicare health insurance part a and b if I could get them to pay for my ... A: Medicare does pay for lap band surgery but there are strict requirements. As long as you can meet ...
Breast Reduction using Medicaid	7/4/2007
Q: I have Florida medicaid and would like to have a breast reduction. How do I find a surgeon and get ... A: Breast reduction is usually done by a plastic surgeon and considered cosmetic so I doubt most ...
Worried	7/3/2007
Q: We recently saw the Michael Moore movie "Sicko" in which a former insurance employee told of his ... A: Yes unfortunately this does happen. Insurance companies do audit claims periodically and see if ...
need help and mercy	7/3/2007
Q: hi really i am 35 years old i am 225lbs i do have stargiht medicaid cause i am disable i have worset ... A: Medicaid does not pay for liposuction since it is considered cosmetic surgery not medical surgery. ...
Humana is not paying	7/1/2007
Q: My dad has Medicare A and B and when the prescription sign up first was required he signed up for ... A: Welcome to the world of insurance claims.....this is very common believe it or not. First thing ...
LAP BAND SURGERY	6/27/2007
Q: I HAVE MEDICARE AND MEDICADE A&B PLUS HELP FOR BEING BELOW POVERTY LEVEL I GUESS. I AM GETTING LAP ... A: Medicare and Medicaid have guidelines and requirements that need to be met in order for them to ...
we are in Arizona	6/26/2007
Q: My step daughter is 17 and she wrecked her truck. the bills have started coming in and they are ... A: In most states, the answer is yes. Once she turns 18 years old, have all the bills sent to her ...
Aetna's refusal to pay office visit	6/24/2007
Q: Tricia: From a list of Aetna's in-network providers I unwittingly chose a medical person who is part ... A: Most insurance companies have this guideline.........however if it was not clear to you or if ...
Insurance Issues	6/23/2007
Q: I was recently diagnosed with a TMJ disorder (complete disc dislocation, osteoarthritis, and fluid ... A: Your insurance company is saying that you are liable for that amount. They denied the procedure as ...
Insurance Issues	6/23/2007
Q: I was recently diagnosed with a TMJ disorder (complete disc dislocation, osteoarthritis, and fluid ... A: Did your insurance pay for any portion of the bill? Most EOB's state what the patient will be ...
moving medicaid services to other states	6/21/2007
Q: a disabled woman getting SSI and Medicaid LT-PCS services is planning on moving back to Louisiana ... A: Medicaid's website for Louisiana has alot of information for hurricane evacuees'........go on to ...
Appealing exclusions	6/15/2007
Q: My son was injured surfing, broken cheek bone, nose. He has Blue Shield California. On the way to ... A: If your insurance denies any of the bills, then appeal them according to their denial. When an ...
Medical ins. for family with a child with Diabetes	6/11/2007
Q: My husband recently started a new job. We have a 7 year old daughter with Diabetes. This insurance ... A: You need to review your specific policy to see what it says about preexisting conditions.....every ...
How can I get Medicare and Medicaid to pay for TMJ?	5/26/2007
Q: .I need help! I have been diagnosed with TMJ. I live in Georgia and cannot find a Dentist that will ... A: I checked on the Internet and their is a Doctor in Gainesville GA who treats TMJ ...
How can I get Medicare and Medicaid to pay for TMJ?	5/26/2007
Q: .I need help! I have been diagnosed with TMJ. I live in Georgia and cannot find a Dentist that will ... A: Medicare will pay for dental services only if in the hospital and they are limited. I would suggest ...
Medicaid and primary insurance	5/25/2007
Q: I became pregnant while currently enrolled in college. I received health insurance as a dependent ... A: You usually need only to prove that your other insurance carrier will not pay........so send the ...
Medical Bill for A Visitor	5/24/2007
Q: My Mom came to USA to visit me without any insurance, but one day she was sick and I took her to an ... A: Perhaps go on the Internet and look for such laws------use search something like "out of the country ...
Medical Bill for A Visitor	5/23/2007
Q: My Mom came to USA to visit me without any insurance, but one day she was sick and I took her to an ... A: You are not liable for your mother's bills........unless you signed something at the hospital saying ...
lap band surgery	5/23/2007
Q: I have keystone health plan east medical ins. it is an HMO, do you know if they cover lap band ... A: Alot of insurance companies are now paying for lap band surgery with some requirements. Each plan ...
pre-authorization of hospital tests	5/21/2007
Q: My husband had a prostate biopsy on 12/7/06 and the next week his urologist phoned and told him that ... A: I think I would call the Dr's office first and see what they did. They should have called for the ...
Denial of precertification	5/17/2007
Q: I recently submitted a pre-certification request to my insurance company (an HMO) for a complete ... A: Insurance companies deny alot of pre-certs even if your Doctor feels it is necessary. Insurance ...
medicare supplement	5/17/2007
Q: I was enrolled in medicare A &B in 91 then did a trial work from 2001 -2005. I never cancelled my ... A: You have no question here so unsure what you are asking. If Summacare requires you to have Medicare ...
medicare advantage problem	5/11/2007
Q: I have two problems that stem from BC/BS misleading me and giving incorrect information. I take a ... A: It is very difficult to fight BCBS......they are the worse insurance company to win with ...
Dentist Insurance Issue	5/10/2007
Q: I have been seeing a dentist for 3 months now for a crown/bridge restoration that usually takes 4 ... A: Alot of insurance companies will not ask for refunds however alot are very active on asking for ...
CIGNA approved, THEN denied??	5/9/2007
Q: I have in my hand 2 letters. One approving pre certification for my preventitive mastectomy (I am ... A: I would call Cigna right away and ask them what is going on. Explain that you did receive an ...
Problem w/ Doctor's Office	5/7/2007
Q: I have a PPO w/ a $300 deductible. I went to a new physician and paid my deductible in the first 3 ... A: It is common practice in the medical field to not refund any overpayments until all the ...
Bypass Surgery	5/7/2007
Q: My insurance company paid for my bypass surgery I had in December. Now, I have lost 75 lbs, My ... A: Unless the tummy tuck is needed for medical reasons, most insurance companies will not pay. What I ...
UHC denial	5/2/2007
Q: I thought I had authorization for sclerotherapy (check spelling?) on my leg veins which were very ... A: Yes you can always appeal a denial. What you need to prove is that it was medically necessary for ...
Friend's bone stimulator bill	4/28/2007
Q: So I have a friend who a few years back got a bone stimulator for her leg. The people who gave her ... A: I would have your friend call the bone stimulator company and put some blame on them. Have her tell ...
speech therapy	4/26/2007
Q: Is there any solution to denials for speech therapy as "developmental" for children who are ... A: You need to use a code that describes the condition as a neurological disorder instead of a ...
MEDICAID SUBMISSION FOR APPROVAL	4/24/2007
Q: I AM PREPARING TO HAVE THE LAPBAND SURGERY VERY SOON MY BMI IS 40+ AND I AM 25 AND 308LBS, I AM ... A: What I would suggest is to go on your state's Medicaid website and find their exact requirements for ...
cosmetic surgery	4/23/2007
Q: how can i get my ins co. to pay for cosmetic surgery? its ohio medicaid- buckeye community health- i ... A: Most insurance plans do not cover cosmetic surgery......they are only liable to cover procedures ...
Unpaid medical bills - return to the US	4/20/2007
Q: Related to the question that was asked by Mahesh on 06/16/06 regarding his Father’s huge medical ... A: You have usually a year to appeal with an insurance company however some are more. Check the denial ...
Medicare HMO	4/19/2007
Q: If a patient has Medicare HMO (i.e. Evercare, WellCare,etc) and Medicaid as secondary and is ... A: I depends on what the EOB (explanation of benefits) from Medicare states. If there is a balance ...
Getting my insurance company to pay!	4/18/2007
Q: I currently am insured, but since my medication has now come out with a generic, I was required to ... A: It depends on your policy......most insurance companies have drug exclusions and if they list ...
insurance	4/17/2007
Q: Yes i have Medicade and Healthease im disabled on social security they sent me my medicare card do i ... A: In most states once you are on SSI for 24 months, you become eligible for Medicare. Medicare then ...
Lap band surgery	4/17/2007
Q: I have United Health Care. My doctor has agreed to campaign to get my insurance to cover the Lap ... A: Check your policy with UnitedHealthCare to see what type of guidelines they may have for this ...
in-network problems	4/12/2007
Q: I recently had a myelogram done at a hospital that is "plainly" listed on my heatlh insurance's web ... A: This does happens alot.........it is up to you to ensure that everyone that is used is in the ...
19 yr. old & health Insurance	4/2/2007
Q: Tricia, I have a 19 year old son who attends college and works part time. Our current health ... A: Many states are now increasing the time you can keep your child covered whether or not they attend ...
medicare part b	3/31/2007
Q: how much does aarp charge for a supplement to medicare part b? A: AARP has different rates and different plans.......so it depends on the state you live in and the ...
Hardship Cases and Physician Discounts	3/30/2007
Q: We need to know the regulations regarding discounting patient's services and writing off hardship ... A: Routine waiving of copayments is in violation of laws in most states. Copayment write offs should ...
Can the Docotrs office do this	3/26/2007
Q: Thanks again A: You are in your right to think that this Doctors office submitted all copays to your secondary ...
participating doctors	3/20/2007
Q: I need a list of the doctors who take medicare in onslow county,n.c. A: I went on Medicare's website and listed below family Dr's in your county. Not all have telephone ...
un-paid insurance claim	3/19/2007
Q: My son (15 yeas old) had surgery on his knee. The insurance company BCBS of Oregon, refused to pay ... A: Since BCBS already denied it, the next step is an appeal. You need to prove that the surgery was ...
re; will medicaid pay	3/16/2007
Q: i am 55 and i have health problems, diabetes, hbpetc. i am 5'2 and weigh 260 lbs. i am looking in to ... A: I attached the following information from Medicaid's site. Medicare and Medicaid usually follow the ...
Provider Write-Offs	3/10/2007
Q: I saw an earlier question from Marshall, along with your responses, regarding whether it is a ... A: Could the insurance company take action against the patient probably not and very ...
Is it a therapy visit or a specialist visit?	2/21/2007
Q: . I have been seeing a dermatologist for my psoriasis. He recommended Photo Chemo Therapy, which ... A: Usually this is the way it works........if you go to the Dr's office for the treatment it is ...
Paying off medical bills	2/19/2007
Q: I have a few medical bills that I'm paying on from when I was in the hospital in November 2006. I ... A: Yes they can.......unless they did agree to you making payments and if this is the case, get it in ...
Insuance not paying claim	2/16/2007
Q: My parents have a PPO plan and back in July my mother had scheduled surgery. They were careful to ... A: I think you are saying that the insurance company after your appeal only paid $156 towards the bill. ...
Medicare Refusal to Pay	2/2/2007
Q: On June 27, 2000, I took a test at Kern Radiology. I had Medicare and Medi-Cal at the time of the ... A: You need to call Medicare directly to find out why they denied the bill. The phone number should be ...
implant for birth defect	1/24/2007
Q: how do you get an insurance to reconsider surgery for implants because you have two different size ... A: You can do an appeal with your insurance carrier. Get your Doctor to write a "letter of medical ...
Being Bill Additional Charges & Dental PPO Aetna	1/23/2007
Q: I have Aetna Dental PPO through my husbands employer, I had to get a root canal on a first molar, ... A: It is not up to Aetna to advise employees of the change of coverage but the employer. Usually ...
Medicare Part B	1/22/2007
Q: Exactly what is Medicare Part B. Is it the supplemental insurance people purchase to supplement ... A: Medicare Part B is for Medical outpatient care such as Doctor services, preventive exams, lab tests, ...
medicare/medicaid	1/20/2007
Q: My 76 year old mom recv'd $86K inheritance last week. She lives in HUD housing and receives ... A: Every state is different so I do not exactly your state's laws nor am I an attorney, however ...
Medical Coverage	1/12/2007
Q: I have been suffering for a year and a half from severe ribcage pain. I have been to litteraly ... A: Usually insurance companies do not pay for travel when you visit an out of state ...
Preexisting Condition or Not?	1/11/2007
Q: My husband was last seen for his knees in '98 or '99. We have just recently purchased health ... A: It depends on your specific guidelines with your health insurance carrier.........all are different. ...
Desperate for advice	1/6/2007
Q: I have a hernia i believe i had it for awhile my doctor told me to exercise and it will go away. Its ... A: I really do not know if that is possible..........perhaps call your Doctor and ask him/her. I would ...
medicaid	1/5/2007
Q: I am 7months pregnaant, and work as s temp, i currently have insurance thru the agency which doesnt ... A: Each state has different guidelines for Medicaid......you must make less than a certain amount and ...
gastric by pass	12/30/2006
Q: if i have aetna hmo what are my chances on getting approved for the surgery A: There are many types of HMO plans under Aetna....some may pay and other may not. You need to call ...
HMO Emergency Situation	11/20/2006
Q: My sister was sent to the Fauquier Community Hospital (in Virginia) emergency room by her HMO ... A: You need to write an appeal to the HMO and state just what you did above. Whenever an insurance ...
Medicare and tummy tucks . . .	11/16/2006
Q: I am thinking to get a bypass surgery soon, and this may be a little early to think of this, but I ... A: I have had no experience with this but I would think they would not cover this type of surgery due ...
HMO refuses to pay after surgery approved	11/1/2006
Q: Mission Hospital Affiliated Physicians gave us an approval for a non elective surgery for my ... A: You need to convince them that they made a mistake on their end and not to put blame on you. Send a ...
unpaid med bills	10/29/2006
Q: I bring in 888.00 a month on SS. I have medicade/medicare. I have had to borrow money from my bank ... A: Yes I would call your bank and tell them that you do not authorize the monthly payment. Then call ...
Health Insurance for Non-Fulltime student	10/24/2006
Q: I am 21 years old and currently under my dad's company insurance through Blue Cross as a full time ... A: Usually you need to go to school full time in order to be covered. However all insurances are ...
Medicaid as secondary insurance	10/20/2006
Q: My practitioner accepts Medicaid. After my wife stopped working (pregnancy and I am a student), we ... A: If Medicaid was your secondary than they should have billed Medicaid for the balance that your ...
Tummy tuck	10/19/2006
Q: I had gastro bypass surgery about 4 years ago. I have lost about 100 pounds. I have a great deal ... A: Usually you have to prove to your insurance company that is medically necessary to do this surgery. ...
Denied speech therapy	10/17/2006
Q: I am a mother of a 4 yrs old autistic child. My insrance Co has denied his speech therapy due to the ... A: There is no other way to win but to take their denial reason and prove it wrong.......if you can ...
Doctor doesn't accept my insurance	10/16/2006
Q: I had to have an emergency C-Section in June. My OB performed the operation and I have already ... A: Yes you should have been advised.......since you did your job to ensure your Doctor and the hospital ...
denied insurance coverage	10/15/2006
Q: Can you give me the information on how to get my insurance company to pay for lap band surgery I ... A: If you have met all the criteria then why does your insurance company refuse to pay. There must be ...
what happens if not paid ?	10/12/2006
Q: My wife delivered baby few months back in a hospital. As per the insurance plan she is supposed to ... A: If you don't pay your portion of the medical bills then most providers/hospitals will send your ...
Supplemental coverage	10/9/2006
Q: My husband and I just turned 65. If Medicare does not cover a procedure will supplemental ... A: If your secondary carrier is a supplemental policy only then it will only pay the balance of what ...
insurance/anesthesiologist	10/5/2006
Q: My daughter had a baby on 07/28/06. She was pre-registered at St. Mary's Medical Center in ... A: This does happen alot...........find out who authorized River Cities to come in......if it was the ...
tummy tuck	10/5/2006
Q: hi my name is michelle am looking for some help to get a tummy tuck or lipo my insurance denied it i ... A: Ask the Dr's office to call your insurance company using a proper code (CPT code) to see if you ...
Writing off a copay amount	10/2/2006
Q: Is it illegal to 'write off' a copay amount amount before billing an insurance company? I'm still ... A: Yes it is illegal to write off any copay amount either before billing or after. Insurance companies ...
INSURANCE PROBLEM	9/18/2006
Q: WE ARE INSURED WITH BUPA. MY WIFE HAD TO UNDERGO A CEASARIAN BIRTH LAST MONTH. THE PAEDIATRICIAN ... A: What you need to check is if your insurance company had a contract or agreement with the ...
denied for lap band surgery	9/16/2006
Q: The reason was because I don't have 5 years of documented morbid obesity. I supplied UHC with all ... A: UHC has strict guidelines and if you don't meet them they can and will deny your coverage. You ...
Letter of medical necessity	9/3/2006
Q: My wife and I have been battling with Cigna for 2 years now over a claim. My daughter is disabled a ... A: You need to continue supplying the insurance company with the information they request to finally ...
IV Vitamin C	8/28/2006
Q: I was wondering if you could help find the correct CPT code for IV Vitamin C treatments which are ... A: I do not know of the CPT code for Vitamin C treatments.......I did a quick look on Medicare's site ...
ins claim	8/26/2006
Q: I bought my husband a keyboard to help him communicate because he had a stroke it has a speaker on ... A: You can appeal their denial....usually twice...........however you would need something probably ...
work ethics	8/23/2006
Q: I have made an error with regard to not requesting the complete information with initial ... A: I would be honest and tell your manager...........not doing so may jeoparize someone not getting ...
UHC & MEDICARE DENYING CLAIM