Has anyone hired a benefits advocate? (medical, hospital, doctor, surgery)

[leighland]

We are trying to navigate a coding problem between the doctor and the hospital and both wont budge. Has anyone hiredd a benefits advocate for a fee to help us among dr-hospital-health insurance? Thanks!

[Angie682]

I worked for a patient advocate company. I have personally reversed over 5 million dollars in wrongfully denied claims. Our company worked on a contingency fee basis. If we did not overturn your denial we did not get paid.

Coding issues are fairly easy to fix. There are some providers that will not change diagnosis codes, even when they are clearly wrong. How much is the fee they are charging you?

[leighland]

I dont have a company yet. Do you recommend your company? Can you post the website?

My surgeon has procedure as outpatient drs orders 23 hr plus observation.
The hospital has the procedure as inpatient and the entire $54,000.00 has been rejected by my ppo

I cannot get the hospital to fix it

Thanks

[Angie682]

OP sent you a PM with the info! Good luck!!!

[Angie682]

I am an appeals supervisor. Why exactly did your insurance company deny coverage for the inpatient claim? Was it denied as not medically necessary or no pre-cert was obtained ? Did the insurance company feel the service should have been billed as OP/observation and not inpatient?

Although a physician orders a service to be outpatient with observation, sometimes complications arise after surgery and an inpatient admission is necessary. Did any complications arise which would have justified keeping your spouse as inpatient? Was there a miscommunication between the physicians office and the facility?

I have not worked for the company I recommended in many years. If they still work on a contingency fee basis, meaning no fee to you unless they deliver have them review. Steer clear of anyone that wants to charge large sums of money upfront.

The important thing to remember is if the insurance company's stance is the surgery should have been performed outpatient vs inpatient address the following in your appeal letter

1. Any medical reasons that your spouse needed to be kept inpatient such as complications that occurred during or after surgery. Obtain the medical records from the hospital. Have your doctor write a letter of medical necessity supporting why the patient required inpatient care

2. The only items that technically should be denied on the inpatient hospital claim is the revenue code for the room and board charges. All the other ancillary charges billed on the inpatient claim would have been billed if the services had been billed outpatient. It is very easy for the insurance company to separate the room and board charges as all claims are itemized.

It is highly unlikely you will get the hospital to correct their coding, especially if complications required inpatient admission vs. observation care.

Good luck. These are fairly easy to correct or overturn on appeal.