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So my healthcare ,private, ADMIN by UMR , provided a pre approval to my surgeon's business office. Last week they denied the entire claim by the hospital @ $86000.00 based on a exclusion in an employees handbook. No employee got this handbook and my wife who works in part of the benefits office had to email someone and HR didn't even have it on hand! They had to email it to her 3 days later @ which point it magically appears on UMRs website. So I have appealed it based on the wide open doctrine of medical necessity. So even if you guys have pre approval check with your employers HR on their exclusions! My wife's insurance had 132 employer specific exclusions !"

Recently I also received the Pre-approval. Luckily my Uro checked on it again before scheduling my Implant and the Insurance Co came back with a denial. $86000? WOW that's the most expensive implant I've seen on FT.

I think $86,000 is about 3 times the typical cost.

That UMR through the state of Mo. or Oklahoma?

Hawkman wrote:I think $86,000 is about 3 times the typical cost.

I would have to search a billion old posts but that is about the price Vanderbilt billed for mine. Insurance ended up paying in the 30's I think. United Healthcare has a policy that they only tell if the code is a covered code. They do not give pre-approvals. I have gone round and round with them about that for years. They only determine whether to approve or deny at the time the bill is presented. A#1 ticks me off.

NeedleD, UMR will often give an exact dollar amount you will be out of pocket. I've received those numbers for required pre-pays for retirees that I paid bills for. They need to provide you a date that policy provision was adopted. One court case I was involved in, the judge and lawyers discussed the pay the adjusters receive is based on the how close the final settlement is to the set aside they initially estimate the claim will cost them. The more accurate they estimate what the insurance company out of pocket will be, the more the person handling the claim makes. Also check the doctor coding vs the coding the UMR is denying under. Is your ED secondary to an injury, other surgery? Then the other surgery would be the primary code and the ED would be the secondary which would make it covered as a complication from the first. I hope you get some resolution to this. It sucks big time man. Worst case, demand the hospital accept the regular United Healthcare contracted rate rather than the stick it up your ass billed rate.

Make sure they are going by the handbook for 2018. The Missouri republican super majority has made drastic changes for 2019 including having to go to the market place for supplements and a boat load of no-longer covereds and co-pays. As some retires I do work for regularly told me 2 weeks ago, Missouri has gone from one of the best insurance plans in the nation to one of the most mediocre for 2019. Sorry buddy.

NeedleD wrote:Recently I also received the Pre-approval. Luckily my Uro checked on it again before scheduling my Implant and the Insurance Co came back with a denial. $86000? WOW that's the most expensive implant I've seen on FT.

Oops my fingers get dyslexic 68k$ hospital 2400 for surgeon 2400 for anesthesia and 500 for some Dr I don't even remember, so still gettin up there. Still no word back from UMR

I think in my case the hospital and Dr's have all billed Medicare as well. If Medicare covers it which they do I would end up paying about 4 k out of pocket.

Have your doctors tried running this through with your crushed pelvis code or spine injury code as the primary diagnosis and the e.d. as secondary to that injury? In most cases the primary diagnosis will carry anything that was secondary to it as long as the primary diagnosis is a covered code. Cheers man. Never give up. EVER.

Well interesting question because they say they can only code ED as that was what the consultation was for.