Hi, my wife was recently diagnosed with Kidney Cancer. As is often the case the initial catch was some other CT scan (in this case Cardiac) which spotted something on her kidney.
Hospital immediately ordered a kidney specific CT scan (which was denied) and a follow up MRI which seems to have gone through. In talking to the hospital (very reputable hospital) it sounds like they requested pre-auth of the CT scan in question which was denied, but they elected to perform the CT scan regardless, based on medical necessity.
We were not told of the denial when we went in for the CT Scan. We got home from vacation to find the denial of coverage letter from the insurer. Needless to say, not the most welcome news at an already stressful time. It sounds like the hospital is already disputing the denial and is following up with the insurer w/o our prompting, so at least we have that going for us (although it does look like both sides have outsourced the dispute to 3rd parties, which is not great).
The letter from the insurer indicated we had the right to request full records relating to this denial, which I am doing for my own review and records.
Question is, do we have any recourse here if the hospital never told us about the pre-auth denial? While I am not sure we would have said "don't do the CT scan", we might have at least duked it out with the insurance company up front a bit. While a CT scan is not a HUGE bill, it would nevertheless be an expense we've not budgeted for, and it seems outlandish that we should have to pay out of pocket for something to help prove a cancer diagnosis, whether it was conclusive or not. At the moment I have the urge to call up the insurer and scream "Are you really telling me that you think your 3rd party flunkies who evaluated the medical necessity of this CT Scan are smarter than the doctors at [insert name of world renowned cancer center] ?!?!?!" and also to call up the hospital and say "Why the hell did you not tell us up front the insurer denied coverage?!?!"
Thanks
Hospital immediately ordered a kidney specific CT scan (which was denied) and a follow up MRI which seems to have gone through. In talking to the hospital (very reputable hospital) it sounds like they requested pre-auth of the CT scan in question which was denied, but they elected to perform the CT scan regardless, based on medical necessity.
We were not told of the denial when we went in for the CT Scan. We got home from vacation to find the denial of coverage letter from the insurer. Needless to say, not the most welcome news at an already stressful time. It sounds like the hospital is already disputing the denial and is following up with the insurer w/o our prompting, so at least we have that going for us (although it does look like both sides have outsourced the dispute to 3rd parties, which is not great).
The letter from the insurer indicated we had the right to request full records relating to this denial, which I am doing for my own review and records.
Question is, do we have any recourse here if the hospital never told us about the pre-auth denial? While I am not sure we would have said "don't do the CT scan", we might have at least duked it out with the insurance company up front a bit. While a CT scan is not a HUGE bill, it would nevertheless be an expense we've not budgeted for, and it seems outlandish that we should have to pay out of pocket for something to help prove a cancer diagnosis, whether it was conclusive or not. At the moment I have the urge to call up the insurer and scream "Are you really telling me that you think your 3rd party flunkies who evaluated the medical necessity of this CT Scan are smarter than the doctors at [insert name of world renowned cancer center] ?!?!?!" and also to call up the hospital and say "Why the hell did you not tell us up front the insurer denied coverage?!?!"
Thanks