Author Topic: Prequalification given with false information  (Read 1024 times)

emtfour

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Prequalification given with false information
« on: August 05, 2010, 12:39:24 AM »
When I called my insurance company before my knee surgery, I was told that they would cover 90% and they even mentioned the hospital I was going to see if it was correct. I confirmed that it was the hospital and the agent still said that indeed they would cover the 90%. When I got my bill from the hospital for 23,000 I was appalled and called the insurance company and they said my surgery was done in a "non-preferred" hospital. I told him what they told me at prequalification and he said there was nothing he could do. Help?

PMRNC

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Re: Prequalification given with false information
« Reply #1 on: August 05, 2010, 11:19:39 AM »
There's always a clause the insurance company uses before you are transferred to a rep that says "Benefits are not a guarantee of payment and are based on coverage at the time of service"
Did you get the first rep's name? Sometimes that will help you out. If you didn't then there really is nothing you can do. Double check your provider guide to see if the hospital was listed, call the hospital and check with them to see if they were a participating facility AT the time of your surgery, if they just recently dropped participation you might have a good shot of appeal since you verified they were in network before your surgery. Many of these can be appealed you just have to keep trying, you have a better shot of an appeal than the hospital so don't rely on them to help you aside from giving you information you might need. TECHNICALLY since all you had was a verbal, and if they were not listed in your provider guide, the carrier can deny or pay out of network. It's always much better if you get that information in writing next time, and look at your provider guide and of course make sure you have updated network guides. If that hospital WAS listed in your book but they went NON par before the next publication, that is grounds for an appeal.  Good luck.
Linda Walker
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