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Insurance and rehab question

Old 11-30-2008, 04:36 PM
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Insurance and rehab question

When my daughter went into rehab her insurance okayed 10 days with us paying $1665. After the ten days she went into their halfway house and we paid for that. Now my daughter has received a bill from the insurance company that said they have reviewed her claim and will not pay $3000 of the charges. She was preapproved and that is the only reason she stayed in the rehab part for the 10 days. She was stable on the Suboxone after 3 days and could have gone into the halfway house at that time. The only reason the hospital waited the 10 days was because her insurance had approved it. Now she does not know what to do. She does not have the money to pay for them and I truly believe it is not fair that, after the fact, and when she does not have a choice that she will be owing $3,000. I told her that we would fight it because I know what they told me at the business office at the rehab. That my $1665 would cover the difference. Has anyone else had this problem and what did they do. Thanks, Marle
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Old 11-30-2008, 05:09 PM
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Haven't had this problem....yet....but am curious to hear other responses because my husband is in the process of trying to go to a 27 day rehab and is currently in a detox facility.
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Old 11-30-2008, 05:12 PM
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Bring this to their attention. If they do not respond favorably threaten to get a lawyer. If that doesn't work, get a lawyer.
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Old 11-30-2008, 05:15 PM
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I have heard of this many times. From most people I have heard of they
have had to fight it. Since they preapproved it, odds are she will win it.
I would contact the financial department their.
They are usually willing to help you fight because if
you don't win many times they don't get their money.
That has been what I have heard from many people.

Good Luck, I think you have a pretty good fight.
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Old 11-30-2008, 05:50 PM
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We will fight it because I know what the rehab told me. And they also told her the same thing. The thing is she did not need to stay in the rehab for 10 days. The halfway house is on the hospital grounds and she still saw the same medical staff. So at three days when she was stable she could have transferred then but stayed because they told her that her insurance had approved 10 days. So whoever made the mistake will just have to eat it. Believe me this rehab would not have kept her if they did not think that they were going to get paid. Everything had to be up front. They are also one of the oldest rehabs in the country so I believe that they know what they are doing. Blue Cross is probably the culprit in this. Hugs, Marle
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Old 11-30-2008, 09:12 PM
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Cool Rehabs vs Insurance -- a wee FYI

I know this is 'way' off topic, but reading this thread (and some others in the past), I feel the need to just put in a wee FYI.....

"...She was preapproved and that is the only reason she stayed in the rehab part for the 10 days. She was stable on the Suboxone after 3 days and could have gone into the halfway house at that time. The only reason the hospital waited the 10 days was because her insurance had approved it..."

....and again

"...The thing is she did not need to stay in the rehab for 10 days...at three days when she was stable she could have transferred then but stayed because they told her that her insurance had approved 10 days...this rehab would not have kept her if they did not think that they were going to get paid..."

Unfortunately, this has been the problem with rehabs and insurance companies.....as long as the rehab was getting the $$, they kept a person, even if that person didn't need to remain.....Early on insurance companies were covering folks for quite long stays (some even for months, up to six months and more in some instances), but some of the rehabs were only out for the money and took advantage of the insurance companies...and slowly but surely the insurance companies began shortening the lengths of stays that they would approve.....and now, today, most insurance won't cover a decent enough length stay for anyone.....It truly is a shame.....

I'm sorry for hi-jacking this thread, but I just felt the need to throw this out there.....for what it's worth.....


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Old 11-30-2008, 09:23 PM
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((((Marle))))
I would strongly encourage Megan to file a complaint with the Michigan Dept of Insurance. I would advise her not to say that the service was not needed in hosptial- That is what BC/BS is saying - that it wasn't medically necessary so they want the money back. it is called recoupment and it just plain stinks. Carriers (not mentioning any names, but 3 guesses who i think is the worst) do this all the time and show their word is good for nothing. They pre-auth then medical review later and take their money back. I would strongly suggest that the argument is that she needed rehab for her opiate addiction - she could not be unsupervised and she needed the counseling program as well as the medical detox to make it. It does not hurt to cc every local legislator you can think of and to emphasize the pre-auth and the fact that here she was trying to get better and because she did, they are now trying to recover the money.

Here is the contact info for the Michigan Office of Financial and Insurance Regulation. They also have a website and a complaint form she can download and fax or email in.

OFIR Consumer Services
PO Box 30220
Lansing MI 48909-7720
Or fax to: (517) 241-3991
Or Email to: [email protected]

Wishing you all the best in this battle. Let us know when you win!
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Old 11-30-2008, 11:14 PM
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I have filed numerous dispute claims with Blue Cross (now anthem blue cross) insurance
on my own behalf and for the bills from my son's first rehab.
I have always prevailed but had to be persistent with many calls, emails, etc.
Usually if you have the time and energy to be persistent, you can get a claim paid, at least that has been my experience.
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Old 12-01-2008, 06:35 AM
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Fight it. I had to fight hard for my son to stay in a mental hospital for a week when he was threatening suicide. Talk to the doctors too because a lot of times the language they put in their reports is how the insurance company decides. For example the only way that my insurance company would pay is if they "were actively suicidal, had a plan, and were a direct danger to themselves." if they didnt see that wording they would reject. I just kept going higher up until someone got it approved. If they think you will just go away they will reject everything. I'll warn you though, its a lot of work, a lot of phone calls. I also got my insurance agent involved and they were a huge help becuase they had better contacts.
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Old 12-01-2008, 09:13 AM
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FYI - you're probably wasting your time if you contact regulatory agencies and/or legal services before you have exhausted the appeals process through the ins. co.

Best advice (this from someone who has worked in the industry for near 15 years) -
Become familiar with your plan's appeal procedures and jump through the hoops. If you have a summary plan description, read the section on claims and appeals. If not, contact them in writing and request that information.

Once you have exhausted all your appeal rights, and things still don't go in your favor, then you can contact an attorney and/or a local gov't agency.
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Old 12-01-2008, 11:48 AM
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Marle,
Generally speaking, rehabs verify benefits before accepting a patient.

Most insurance policies require an adult child to be a full time student to be eligible for coverage on their parent's policy. Because of fraud, insurance carriers now almost always require proof that the insured student is indeed a full time student, in good standing. This does not happen until well after the fact.

I am wondering if this might be a part of the problem.

( This bit us big time when we learned that AD never bothered to attend a class and in effect was deemed uninsured. )
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Old 12-01-2008, 12:45 PM
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Out, The rehab did verify benefits before they accepted my daughter. They called me back and said that we would have to pay $1665 up front and that is what I did the day I took her there. When my daughter lost her insurance through us, we picked her up a policy through Blue Cross. She was eligible because of having been insured through Blue Cross on our policy. So her policy is legitimate. They paid $5000 of the $8400 in charges for her 10 ten stay. They have refused to pay for some of the services. When and if she gets a bill from the rehab, I will be calling because they assured us that she would be covered for the 10 days if we paid the $1665. They said that was the difference. So I don't really know what will happen. Maybe the rehab already knew that Blue Cross would only pay that amount. The insurance company paid the bill in November and Megan has not received anything from Brighton yet so we will see. I just want to be prepared because, like I said, she could have gone to the halfway house earlier if the rehab knew that she was not going to be covered. The rehab also knew that we had already paid for a month in the halfway house and they transferred her there when they told her that her insurance benefits had run out. Hugs, Marle
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Old 12-01-2008, 01:03 PM
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I would be inclined to let this sleeping dog lie since the rehab has yet to bill you or your daughter, for the difference. When and if they do, there will be time enough for a battle.

Just curious....what procedures are being denied payment?
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Old 12-01-2008, 01:42 PM
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I had to fight BCBS last summer for the same thing. Found out the people on the 'authorization' line don't know what they are doing. since it was recorded, and I had date/time/person, I won but it was a hassle and worry!

love to you both,
susan
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Old 12-01-2008, 03:07 PM
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Anvil, Megan is willing to call the insurance company. I told her to wait until she gets a bill from the rehab before she does anything since we don't really know if they are going to bill her or not. I am going to play backup since I was the one who dealt with the financial end of things. Megan was the one who called the rehab and made all the arrangements. The man from rehab wanted to talk to me as there was an extra amount that had to be paid up front.

Out, It only says that after further review certain charges are being denied. It did not itemize on the insurance bill.

Megan is doing well paying off old debts. So far she has paid about $2,000 on debt from 2006 and is feeling pretty proud of herself. She still has another $6000 to go and is considering debt consolidation on half of it. The other half is a hospital bill that she is paying on monthly. So I am pretty proud of her and do not want to see her get a bill that she does not deserve. The other ones are hers to own. Hugs, Marle
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Old 12-01-2008, 05:38 PM
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don't worry... everything is a fight with insurance companies. i received a bill from the insurance company for my grandma one year. She was doing physical therapy in November, the thing is, she passed away in September. This unfortunately happens all the time. I am sorry, but its the way they are.
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Old 12-01-2008, 06:07 PM
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Originally Posted by marle View Post
Anvil, Megan is willing to call the insurance company. I told her to wait until she gets a bill from the rehab before she does anything since we don't really know if they are going to bill her or not. I am going to play backup since I was the one who dealt with the financial end of things. Megan was the one who called the rehab and made all the arrangements. The man from rehab wanted to talk to me as there was an extra amount that had to be paid up front.

Out, It only says that after further review certain charges are being denied. It did not itemize on the insurance bill.

Megan is doing well paying off old debts. So far she has paid about $2,000 on debt from 2006 and is feeling pretty proud of herself. She still has another $6000 to go and is considering debt consolidation on half of it. The other half is a hospital bill that she is paying on monthly. So I am pretty proud of her and do not want to see her get a bill that she does not deserve. The other ones are hers to own. Hugs, Marle

I am really glad you are helping her, insurance companies are ruthless and have been known to drive people to the brink. My mom helped me as much as she could being far away but it was too hard her not being here.

I did try but doing it abm was too much for me, it really was. I needed help.
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Old 12-01-2008, 10:09 PM
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I hate insurance. I would definately appeal. If 10 days was preapproved then it should be payed for. I have saved every shred of paper from the insurance company. Counted each day to make sure that my son was given every last day he was allowed before I had to kick in payment. APPEAL!!!!

Editing my post to agree that I would do nothing until you find out if the rehab is going to bill you or not, or maybe they are willing to accept what they were given so far as payment in full. I am in the medical field and we always overbill insurance companies so we get the maximum allowed, but then I never bill back the patient the balance. We accept that as payment in full.
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Old 12-01-2008, 10:38 PM
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I am one of the first persons who would tell you that yes, you definitely need to fight the insurance company.....I know!!! I had to fight them once myself. I was approved for a hospital stay which included surgery [I had a broken ankle (actually broken both inside and outside) and a two broken leg bones]. The insurance approved with the hospital, but after it was all done, they informed me that since I didn't call and obtain a personal approval from them within the first 24 hours they were not going to pay my bill (just a tad over $85,000.00).....I fought and won; after all, I asked them, when was it I was supposed to call.....? My first 24 hours in hospital were taken up with morphine, anesthesia, and more morphine.....lolol.....sure, I could call.....NOT.

But my question is still.....even though the insurance company approved 10 days, since it wasn't necessary for her to remain in the rehab for the entire 10 days, why didn't the rehab have her leave and go early to the half-way house.....? After all, you might have even gotten some of your $1665.00 back......

Just a question you might want to mull over..... (o:


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