Insurance denied revision

[Lost Sheep]

(edited for focus)
They only stated one requirement that wasn't met each time they denied it, until I had completed all of them. It was nerve wracking to say the least and seriously aggravating (say "PISSED").

Got it. Can you spell "War of Attrition?? Wear you down with one stumbling block after another until you either run out of energy or die in the meantime.

A letter to your State Government (whatever official oversees Insurance Companies - every State has one, usually the Attorney General or the Lieutenant Governor's office, but may be in Commerce or something - but every state has one.) with a copy to your insurance company might shake something loose. Especially if they have denied you repeatedly and come up with a DIFFERENT reason for denial each time. Mention that this is a pattern designed to delay performing their contractual obligations. It may ruffle feathers at the insurance company (identifying yourself as a troublemaker) or it may give notice not to mess with you further. Your decision, which is the better tactical move. Fines and sanctions can be levied against insurance companies which engage in bad faith with regard to their contractual obligations repeatedly.

Good luck.

[Gt1956]

(edited for focus)
They only stated one requirement that wasn't met each time they denied it, until I had completed all of them. It was nerve wracking to say the least and seriously aggravating (say "PISSED").

Got it. Can you spell "War of Attrition?? Wear you down with one stumbling block after another until you either run out of energy or die in the meantime.

A letter to your State Government (whatever official oversees Insurance Companies - every State has one, usually the Attorney General or the Lieutenant Governor's office, but may be in Commerce or something - but every state has one.) with a copy to your insurance company might shake something loose. Especially if they have denied you repeatedly and come up with a DIFFERENT reason for denial each time. Mention that this is a pattern designed to delay performing their contractual obligations. It may ruffle feathers at the insurance company (identifying yourself as a troublemaker) or it may give notice not to mess with you further. Your decision, which is the better tactical move. Fines and sanctions can be levied against insurance companies which engage in bad faith with regard to their contractual obligations repeatedly.
Good luck.

Good advice. But a lot of times a company will blame it on the last employee that quit or was fired. That bonehead misinterpeted our policies kind of thing. Fight the good fight. Fight to win. But getting that ounce of flesh is hard to do. Some companies are dislike because they earned it the old fashion way. They are dinks.

[Biker60]

Don't expect that another implant surgeon will do much more to get the revision covered. Even some of the implant gods mentioned on FT would be more then happy for you to just pay the 25k, then fight for you. My implant did not require prior authorization. But for Ed, it was not covered by employer exclusion. If your Medicare that's another story. But, if I needed a revision, I don't expect anyone to fight for it to be covered. I am past 59.5 yo, so taking a distro from 401k would be my plan.but o NB e thing, if the office codes it wrong, then your appeals will always be denied.

[RayChez]

A lot of this is political. The democrats want insurance for all, while the republicans want a person to have a choice whether he wants insurance or he just has to pay in cash on his own. They call it going back to grass roots. The only problem like in California the ER can not deny you treatment if you go with lets say a broken arm etc etc. And the bad thing is either the hospital loses out on income they need to support the hospital or the tax payer has to bail out this person who chooses not to have any kind of insurance. So a lot of these insurance companies that support a republican president like the one we have now, get bullish and do not want to pay, which is wrong.

[RayChez]

To Biker60,
Not sure why you had ED, but like in my case, the ED was caused by cancer on the urethra below the prostate and they removed about two inches of urethra, prostrate to make sure they had gotten all the cancer plus the node glands in the area. So my implant was a necessity caused by cancer to get back to normal. When I had my revision the doctor just posted to the insurance that it was caused originally by cancer, not a cosmetic situation and the insurance companies have paid every cent.

But my understanding is that if it is something you want just for cosmetic purposes, they will not pay.

[MK1965]

My ED was also caused by prostate cancer and RP to remove prostate, seminal vesicles and limphnodes which rendered me 100% impotent. I tried everything possible to recover my erections but that never happened.
MK

[Gt1956]

A lot of this is political. The democrats want insurance for all, while the republicans want a person to have a choice whether he wants insurance or he just has to pay in cash on his own. They call it going back to grass roots. The only problem like in California the ER can not deny you treatment if you go with lets say a broken arm etc etc. And the bad thing is either the hospital loses out on income they need to support the hospital or the tax payer has to bail out this person who chooses not to have any kind of insurance. So a lot of these insurance companies that support a republican president like the one we have now, get bullish and do not want to pay, which is wrong.

I believe that it is way more complicated than your theory. Ok, they drag some non insured case into the ER. The side benefit of the massively inflated list procedure rates now comes into play. Say that the cash/insurance rate this person racks up is $1,000. But the "list" rate is $10,000. Not entirely out of line. So the hospital writes the $10k off as a bad debt. So $10k of income is not taxed cause of the "loss" incurred from the bonehead. Losses offset gains. Because the loss is inflated but payment is accepted from insurance at an agreed to discount rate. Large ammonts of income slides thru basically tax free. The trick is to not get your losses very much above your profits.
One man's opinion.

[Lost Sheep]

A lot of this is political. The democrats want insurance for all, while the republicans want a person to have a choice whether he wants insurance or he just has to pay in cash on his own. They call it going back to grass roots. The only problem like in California the ER can not deny you treatment if you go with lets say a broken arm etc etc. And the bad thing is either the hospital loses out on income they need to support the hospital or the tax payer has to bail out this person who chooses not to have any kind of insurance. So a lot of these insurance companies that support a republican president like the one we have now, get bullish and do not want to pay, which is wrong.

I believe that it is way more complicated than your theory. Ok, they drag some non insured case into the ER. The side benefit of the massively inflated list procedure rates now comes into play. Say that the cash/insurance rate this person racks up is $1,000. But the "list" rate is $10,000. Not entirely out of line. So the hospital writes the $10k off as a bad debt. So $10k of income is not taxed cause of the "loss" incurred from the bonehead. Losses offset gains. Because the loss is inflated but payment is accepted from insurance at an agreed to discount rate. Large ammonts of income slides thru basically tax free. The trick is to not get your losses very much above your profits.
One man's opinion.

Sorry, that does not make sense on the tax basis.

The provider bills $10,000 and gets paid (the discounted insurance company rate) of $1,000. The $9,000 is not written off as a loss. It never was anything but numbers on a bill. Never declared as income and thus not declarable as a loss. The $1,000 is income all right. If the (uninsured) patient had paid $10,000 THAT would be income. But the provider only ever collected $1,000. The uncollected $9,000 is just so much smoke and mirrors.

Now, if they actually paid, say $5,000 for drugs, facilities, bandages, etc. That IS a deductible cost. But whether or not the $5k was spent on an insured patient or an uninsured patient is beside the point.

[Gt1956]

Perhaps my post isn't clear. The $10,000 uninsured "loss" is used to offset the income from the $1,000 that was paid by the insurance companies on other patients.
In the ledger there is a profit column. Doesn't matter what number you want to say is there. The loss column shows a $10,000 loss. So subtract the $10k from whatever is profit. They will pay taxes on $10k less of profit number.
When I had rental properties. The loss column generated more offset to the rental income. Thus a loss on my 1040. Which reduced my taxes on my regular jobs income.
Yes, the loss in both instances is pretty much false. But that is exactly how the IRS requires you to do it on rental property. I'm sure that corporate hospitals have as sweet of a deal as a lowly landlord.

[Lost Sheep]

Perhaps my post isn't clear. The $10,000 uninsured "loss" is used to offset the income from the $1,000 that was paid by the insurance companies on other patients.
In the ledger there is a profit column. Doesn't matter what number you want to say is there. The loss column shows a $10,000 loss. So subtract the $10k from whatever is profit. They will pay taxes on $10k less of profit number.
When I had rental properties. The loss column generated more offset to the rental income. Thus a loss on my 1040. Which reduced my taxes on my regular jobs income.
Yes, the loss in both instances is pretty much false. But that is exactly how the IRS requires you to do it on rental property. I'm sure that corporate hospitals have as sweet of a deal as a lowly landlord.

The hospital never recognized the $10k as income to the IRS, so can never take its absence as a loss. In real estate the "loss" is recognized generally as depreciation or some type of amortization, either of which eventually will be recaptured as income. The IRS always gets their due. In Real Estate it is possible to "time shift" the tax burden, but it is always there.