Tuesday, December 1, 2009


First of all, I know I'm a bad blogger. I was on call for a good part of the week before and after Thanksgiving and I got overwhelmed. After a nice 4 day weekend I am somewhat caught up with bills and cleaning and I got in some great time with my kiddos and my hubby. I also got some great pictures of the kids that I promise I'll post soon. Now, on to the real post.

I was so proud of myself. We got Max's cleft repair surgery pre-approved by our insurance. The bills were coming in and I was staying on top of things. I caught the $800 overcharge for ear drops and got that fixed. I thought I had it all under control. I should have known better. I deal with insurance companies as a patient and a physician and it's never pretty. I am quite positive that the majority of them are trying to trick and cheat people into paying more than they should. So, I wasn't entirely surprised when I got Max's surgery bill and our insurance had declined paying for $3500 of the procedure saying that it was dental. His surgery bill was broken up into three parts. The first two parts they covered fine. The third part was something called a vestibuloplasty. My non-surgeon understanding of this is that they make some incisions near the gum line (recall my freak out of this being a fistula) and pull the tissue mid line to close the cleft. Feel free to correct me if someone has a better understanding of this. So, my insurance declined to pay this part of the procedure stating that it was dental. Even though in my mind (and my surgeon's) they couldn't close the cleft without doing this. So, I thought when I called and explained this surely the insurance company would understand their faulty thinking and pay for the procedure. Wrong. They are still saying it's dental and refusing to pay. They also said that although the surgeon pre-authorized the procedure, he didn't pre-authorize the vestibuloplasty code (who would have known that it wasn't bundled into the cleft repair). I don't think I'm an idiot, but I really don't know how to convince an insurance company that they're wrong when they are unwilling to hear it.

Here's my plan. I've called the physician's office and the physician's billing office to have them talk directly to the insurance company and try to explain (probably they won't listen to them either). I've called my insurance agent to ask him to talk directly with the insurance company (probably won't listen to him either). If this doesn't work I'll file an appeal with letters of medical necessity from the surgeon (since it's an internal appeal I doubt this will work either). I also plan on sending a letter to the insurance commissioner for the state. If anyone has ever dealt with this before or has any other ideas please let me know.


  1. I do thank you for the heads up! Ty is in surgery as we speak. You have got to be kidding me! Fight it, and fight it hard! I would refuse to pay it, until the hospital goes to bat for you and you appeal and appeal again. That is so wrong!

  2. Just keep fighting them on it, Alexis. I think they bank on most people giving up. But I really do hate the medical insurance industry - it's a real racket and I don't know how the people at the top sleep at night.