Question
Our family is under an HMO plan. My wife was having issues with infections etc and needed to see an ENT. We got a referral to see the ENT and after seeing my wife, they determined she needed a tonsillectomy. We gave the ENT our HMO card and my wife was very adamant about asking them to make sure they got the approval for the surgery. They said they did. After the surgery, we started getting bills from the outpatient hospital for the full amount. After a period of time and the HMO not paying them, it was determined the ENT did not get approval prior to the surgery. The outpatient hospital is now coming back to us for full payment because the HMO will not pay. Unfortunately, my wife was required to sign a sheet (immediately prior to surgery)from the outpatient hospital that said we would pay if insurance did not pay or did not pay the full amount. We are going back to the doctor to try and get them to pay but what are our options here? What if the doctor refuses to pay? I would assume they are fully aware (even if we didn't ask) that you must get pre-approval for HMO procedures. Thank you very much
Answer
Hi Carrie!
It is the providers responsibility to get a pre-approval prior to any service and the hospital should have also checked.
So call the Dr to find out who dropped the ball and then go from there.
Usually if a provider does not get a pre-approval than they must "eat" the bill.
Also if there is an honest answer for not getting a pre-approval sometimes the insurance company may reconsider after an appeal.
Good Luck!
Tricia
