But the Doctor Said I Needed It

by Joanna Smith on Sep 29, 2010

A few weeks ago, one of my clients called me, frustrated with a bill he had received for a stay in the hospital.  He had been admitted for surgery, and while in the hospital had developed an infection:  that had  necessitated a longer stay.  My client became depressed, and the hospitalist (the physician that was overseeing his care) had come to him and said that he felt a psychiatrist should see him, that it was “an integral part of his care” to recover from the surgery and infection.  My client agreed to the visit from a psychiatrist.

When the insurance company received the entire bill for the hospital stay, they denied payment for all of the psychiatrist’s visits, saying that they had not been pre-authorized by the insurance company, so they would not be covered.  The hospital then billed my client for the psychiatrist’s services.

My client called me, saying, “My doctor said I needed this; how could I possibly have known it needed to be pre-authorized?  I was sick; he recommended a treatment and I agreed.  How can they charge me for it?”

I could see immediately what had happened; this is a very common event when someone is in the hospital, and it frequently leads to an INITIAL denial by the insurance company.  When I called the insurer, I said “you have this happen all the time: how can we get this reconsidered?”  The insurer requested medical records to review.  Once they were provided, the claim was paid.

Points to remember:

  • Review all medical bills carefully; make sure you understand the charges.
  • Team with the hospital billing department; they can assist with sending medical records.
  • The first review of a claim frequently is a denial.
  • Appeals are the rule of thumb:  be prepared for two or more.
  • Work patiently with everyone:  you will get a better response if you are respectful but determined.
  • If your bill is very complex, you might want to hire a medical coder to review it and make sure the coding was done correctly.