I went to a local Atlanta hospital about 10 days ago to have an outpatient surgery on my L4-L5 vertebrae performed. The neurosurgeon told me beforehand that I may be out the same day but they could decide to keep me overnight. He was concerned about the fact that Parkinsons patients, of which I am one, sometimes react oddly to anesthesia when coming out of it. In addition, I have AFIB issues and sleep apnea. The hospital even told be during my pre-op testing a week before the surgery to be sure and bring my CPAP machine.
So, I had the surgery on Thur. Oct. 10 which ended about 10am. I laid in the recovery room until about 5pm and then they wheeled me to my own private room. No body told me I was being admitted or asked me if I wanted to be admitted. I spent all day Friday and Saturday with an iv in my arm, electrodes on my chest and an oxygen hose in my nostrils. I kept being told that they were waiting for me to get approved for discharge and to obtain a walker. I was there until 9pm Saturday night and was finally discharged.
Today, 10/20//24, I got a letter from the hospital saying my request was denied.
The reason for denial was: admission to an inpatient level of care.
Did you need pre-approval for your surgery? Is the hospital in-network? Assuming those are not at issue, then your surgeon and other doctors can update the procedure codes to indicate that inpatient care was medically necessary, and why.
Yes, an authorization was created in advance for the surgery, which was outpatient. Yes, the hospital is in-network. The surgeon told me before the surgery that I would probably go home the same day but it was posssible I would have to stay overnight.
Consider the following options:
Contact the surgeon’s office to make sure they have submit the correct diagnosis/billing code for the reason(s) you were admitted. Find out who in the office handles the claim denials and make sure they copy you on all correspondence between the surgeon’s office and the insurance company.
Contact the insurance company and make sure that they have obtained all the information from the surgeon’s office. Get any correspondence in writing
Get input from your insurance agent/broker if the issue has not been resolved after the above efforts.
File an appeal with the insurance company if the claim is still denied. healthcare.gov has information on the appeal process.
Consider having the Patient Advocate Foundation act on your behalf whenever you feel you need assistance.