Question
Hay, My insurance is Aetna HMO which we all know needs a referral from your pcp. Well, my pcp sent me to a cardiologist for a stress test. the test came back abnormal and I was sent by the cardiologist to have a outpatient cardiac cath done. So, I had all this done with pcp telling me they had referral, even cardiologist seen me and did not catch that insurance company noy notified. So, I get the cath done and had to be hosp overnite for bleeding. Get bill later and insurance had denied all but inpatient visit! My pcp sent a letter stating that this was their mistake and was an oversight on their behalf. Still refuses to pay the claim. So directed to do so by my hospital I do a level 1 appeal, STILL DENIED. Even pcp sent another letter....So, now I am doing a level 2 appeal...Also, let me add I am an employee at this hospital and the holder of this insurance policy!
I have the pcp saying it is half their blame and even the cardiology office states the same, however I am the one that the hospital is looking at for a little over $7,000.00 !! What do you think my chances are and can I do if the level 2 falls through? The hospital I work at is a HCA affiliated and that is where the next claim is filed is at the appeals board with the HCA board....Let me also add everything being done is within all the time limits allowed for the appeals... What is your thoughts on this matter? Thanks Pam
Answer
Hi Pam!
Usually with an HMO plan if the provider does not get a referral, they eat the bill not the patient. Look at your denial to see if you are responsible if it is not paid.
If you are, then before your final appeal I think I would get your H/R department to call Aetna for you to see if they have any pull trying to get this claim paid. They usually have alot of pull since they determine what insurance carrier they will use for their employees.
However I would again look into if you are liable for a claim not authorized.....HMO plans are usually specific that if the provider does not obtain an authorization they do not get paid and the patient is not responsible. So check into this before you do anything.
Good Luck!
Tricia
