- September 20, 2023
- Posted by: legaleseblogger
- Category: Related News
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Title: AI Legalese Decoder: Providing Solutions to Insurance Claim Denials for Unexpected Inpatient Stays
Introduction:
Hey all,
Never thought I would be posting here, but here I am, seeking assistance with an unexpected predicament. Last week, I underwent a lumbar microdiscectomy, which was supposed to be an outpatient procedure requiring only an overnight stay at the hospital. I had obtained pre-approval from my insurance for the surgery, as advised by my doctor’s office. However, post-surgery complications prolonged my hospital stay, resulting in an unexpected inpatient status, exceeding the originally anticipated 23-hour timeframe. Despite my insurance pre-approval and the surgeon’s delayed follow-up, my insurance company denied the entire claim, leaving me with a staggering $75k bill.
Detailed Account of the Hospital Stay:
Following a smooth admission process, I arrived at the hospital around 5:45 AM, proceeded with registration between 6 and 6:30 AM, and underwent the surgery at 7:30 AM. However, my body’s response to the procedure was not favorable. I experienced a high heart rate, escalated white blood cell count, and bladder issues, which necessitated an extended hospital stay of approximately 36 hours. Unfortunately, this duration surpasses the aforementioned 23-hour threshold, prompting the insurance claim denial.
AI Legalese Decoder: Assisting with Insurance Claim Disputes:
Amidst this financial setback, I recently discovered an innovative solution that could potentially alleviate my situation. The AI Legalese Decoder is an advanced technology designed to decode complex insurance policies, identify legal loopholes, and offer valuable guidance in disputing claim denials. By utilizing this cutting-edge tool, individuals like myself can receive comprehensive legal insights, empowering them to challenge unjust insurance decisions.
Key Questions and Legal Recourse:
Given the frustrating denial of my claim, I find myself seeking answers to pertinent questions along with potential steps for legal recourse. Firstly, based on the breakdown provided on my insurance website, it appears that I should owe nothing since the hospital billed the services as inpatient. However, I am uncertain whether this information is accurate and whether I will indeed be exempt from payment obligations.
In the unfortunate event that I am held responsible, I am keen to understand the available legal actions that I can undertake to address this unfair burden. Personally, I firmly believe that this excessive financial liability should not fall upon my shoulders, given my adherence to the necessary pre-approval process. Had I been informed of the possibility of exceeding the 23-hour limit, I would have actively pursued an earlier discharge.
Conclusion:
To summarize, I find myself in a troubling situation, facing significant financial implications due to an unexpected denial of my insurance claim for an inpatient stay. However, with the advent of the AI Legalese Decoder, I am hopeful that this advanced tool can provide me with valuable insights and legal strategies to challenge the claim denial. By understanding my rights and potential courses of action, I aim to navigate this complex issue and ensure that I am not unjustly burdened with the substantial medical expenses. Any advice or information regarding my specific circumstances, particularly within the jurisdiction of New Jersey, would be greatly appreciated.
Thank you in advance for any assistance you can provide.
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AI LEGALESE DECODER: BRINGING CLARITY TO THE COMPLEXITY OF LEGAL TERMINOLOGY
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First step is to file an appeal. I would contact the hospital. Trust me, they are used to this. They may already be filing an appeal. But you should too. There are multiple levels of appeal. It’s likely hidden on their website somewhere. But just call and appeal. If it’s denied, go to the next level of appeal. It’s a standard business practice: deny, deny, deny, and eventually cover when it looks like you won’t quit. If they deny 10% of claims and 99% file appeals, they’ve save 1% of claims off the bat. With each level of appeal, more and more are paid. They will use anything to deny a claim, but the lack of documentation for a longer stay is very common. VERY common.
It’s shitty, but until they get an appropriate practitioner to actually read your chart, it’s going to be rejected nearly automatically because you stayed 36 hours for an outpatient procedure. Of course you have a good reason, but without pounding that into their heads, they’re going to take the negligent view that you had an unapproved stay.
Thanks everyone for the advice. I spoke with the hospital’s billing department and they basically acknowledged that it needs to be changed to an outpatient procedure then re-submitted to my insurance. They are in the process of doing that now and they said to call back next week to see if there are any changes. I also recorded the call in case I need it later.
My wife went in for an urgent surgery once. We got insurance approval quickly. When the surgeon opened her up, he found the problem to be different than what they had anticipated. They fixed the problem, but the insurance denied the surgery claim because this new procedure they did wasn’t prior authorized !!. We had to end up paying out of pocket. Stupid system!!!!!!
I had a similar situation. My doctor wrote the insurance company a letter explaining in detail why the overnight hospital stay was necessary. The insurance then paid the bill. Good luck!
It could be something as little as needed to change the billing codes. You suffered a complication that necessitated a hospital stay. The insurance company may need this spelled out for them, they auto deny A LOT.
DonÔÇÖt panic, let the doctors office fight it out with the insurance company. If they exhaust all options and insurance still wonÔÇÖt pay, you can go to the insurance commissioner of your state and file a complaint.
file an appeal with your insurance rep.
I wonder if it was an observation stay. Typically stays that short are considered observation (this all depends on the admission order, did they change you to OBS or inpatient? Whatever that order states is how it has to bill). For 2023, observation uses inpatient codes but the stay is still considered observation (which is akin to outpatient).
Definitely keep up with the billing dept; they can work with you to appeal and such if the claim is still denied. Our organization tries multiple avenues for payment before just billing the patient; I hate when healthcare orgs do that. Like people just have tens of thousands of dollars just sitting around. Good luck, they really should be able to get this ironed out. ThereÔÇÖs documented medical necessity for the longer stay.
Did you need insurance pre approval for outpatient? If so maybe they got the bill and somehow someone added the night inpatient on the bill even though You say the Dr office was only going to bill for outpatient even though you stayed a night and day extra in hospital. They hadnÔÇÖt pre approved the stay overnight only outpatient.
Contact a patient advocate, theyÔÇÖll generally help you navigate the ins and outs of how to get around this.
Did you appeal? Also there is a P2P appeal option.
Nal but my insurance company is saying something I did wasn’t medically necessary. I know I’m not paying for it though. I had insurance for a reason. It’s their bill. So I just wouldn’t pay it.
If they won’t budge go bankruptcy.
Your insurance company telling you that you owe nothing is a good hint.
I can tell you that I’ve faced a similar situation and, because I used an in-network provider, my health provider didn’t get paid and I owe nothing. Being an in-network provider did matter for my case.
Just as you have responsibility to your insurance company based on your policy, the in-network providers have responsibility to the insurance company based on their contract with the insurance company. It sounds as if your health provider didn’t follow the rules established by the insurance company. As a result, the insurance company isn’t paying them AND the health providers can’t bill you.
In my case, I had to use an ambulance to get to the hospital and, fortunately, the ambulance that serves my city is in-network. The ambulance company failed to provide all the information my insurance company required and didn’t follow up in the time required with their contract with the insurance company. As a result, based on the contract between the insurance company and the ambulance company, I can’t be billed. Tough luck for the ambulance company.
Also check with your employer? Does your employer subscribe to a health advocate service? If so you can call give them all the details and they will help you navigate everything including writing the appeal for you. I was on the hook for 10,000 and health advocate helped me file a successful appeal. Using their help saved me hours of time.
Is the facility and the physicians in network?
If so, it is the responsibility of in network providers to follow the rules of the contract they have with the insurance company. They should be working to either appeal or submit the proper claim.
I run a clinic and insurance will just deny 5-10% of all claims, even if the claims are for the same patient, same procedure and same CPT and Dx codes a week apart. It is just part of what insurance does. 99% of the time we are able to appeal and resolve without the patient ever having to get involved.
My wife had an eight hour surgery, and the insurance company denied coverage for anesthesia.
NAL
Resubmit! On three occasions now IÔÇÖve done it, or told someone to resubmit, and every time itÔÇÖs been covered after resubmission.
I had a friend that worked in the department within one of the major insurers that approves/denies claims and prior-authorizations. She told me that they were trained to deny every third claim/authorization without prejudice. DidnÔÇÖt matter what it was for, or if it was a covered expense.
Complete shit, but IÔÇÖm pretty sure she was being truthful based on my own experience, as well as that of a friend and my mom (mentioned above).
At the point your vitals were a concern by a doctor, the Hospital Doctor should have changed your admission to an inpatient.
One of your doctors needs to document that the medical issues required additional time in the hospital, and your status should have been changed to inpatient. The hospital will then resubmit the claim to your insurance, and it should be covered at that time.
I’m a spine surgery physician assistant in NJ. The hospital I work out of has a department to review charts and catch issues like this so proper documentation is completed before the claim is submited to insurance.
I hope you’re recovering well! These billing issues can be pretty stressful.
The surgery itself was outpatient, but you had complications from the surgery which necessitated observation for over 24 hours. This does not change your surgery to inpatient.
Part of the problem may be how the hospital billed the insurance company. They likely used the wrong coding, resulting in the claim being denied.
Contact the hospital and speak to billing. Likewise, talk to your health insurance and file an appeal, and be sure to indicate your overnight stay was due to complications, not part of the original surgical plan.
This isn’t that uncommon. People develop complications from outpatient surgery all the time. My guess is the hospital billed your stay incorrectly.
Call the surgeon, not the hospital. Ask the surgeon to change the CPT codes so that your hospital stay is covered.
It sounds like the surgeon just coded as a observation stay, when they should have coded an inpatient stay.
Talk with your surgeon’s office about their billing codes. My husband had an overnight hospital stay after an outpatient surgery but was never technically admitted to the hospital. It was billed as extended recovery.
That 23 hour rule isn’t really a thing anymore, I’m a coder (the one that processes the chart info for the bills) I’ve coded observation stays of over a week. It really has more to do with the level of care. If a doctor (either your surgeon or whomever dealt with the complications) never wrote an order making it an impatient- you were not an impatient.
Start with calling the billing department at the hospital/surgery center and ask for a manager if needed, they need to look at what they billed and be sure it was all appropriate first, escalate if needed. Talk to you insurance too, there is an appeals procedure too.
Need more info. You said the insurance denied it, but on the insurance website it says you owe nothing? What did you receive as a denial?
It sounds like the insurance denied the claim, most likely for incorrect coding. ThatÔÇÖs common and an easy fix, but not something you can do. The hospital needs to fix it.
If the insurance says you owe nothing, then you should be OK.