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I googled "Coventry Denied MRI" interesting reading, sounds like this is a pattern, I may be dropping them from my briefcase!
Coventry Georgia Rate Alert!
- Thread starter AndreaSti
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- Thread starter
- #12
- 630
It's weird but they are really strict on joint problems, but I thought they just didn't want them (rate ups, denials). Haven't had any clients being denied testing for an injury though. Keep us updated on what happens. Unless I am missing something here, or not getting all the facts, this just doesn't sound right.
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Nope all facts are correct, I will update as soon as possible, the doctor is appealing so the customer is limping around for now!
- Thread starter
- #14
- 630
Yeah that sucks, excuse my language. I don't blame him though, wouldn't want to be stuck with that bill.
Unless Coventry's contract is different from everyone else, an MRI is subject to the major med deductible. The Blue Book puts the cost of a knee MRI at slightly over $800.
If the pain is that bad, have the MRI while waiting on the appeal since they are probably going to have to front the bill any way.
If the pain is that bad, have the MRI while waiting on the appeal since they are probably going to have to front the bill any way.
- 424
True, the MRI will be right at $1000 he has a $2500 deductible but if they deny after the appeal then the $1000 will not go towards the deductible and if the decide he needs to have surgery what then?
Yeah, but what if he really needs the surgery? How long is he going to wait? And what are his options otherwise?
You can't move him to another carrier.
He can go without coverage for 6 months and get in PCIP.
Frankly, I don't think Coventry or any other carrier has a leg to stand on (no pun intended) when it comes to denying claims that are medically necessary.
- 424
He evidently needs the surgery or some help, he said he is going to go ahead and have the MRI and if surgery is needed that also, said if Coventry denies any he will be contacting (1.) The insurance commisioner (2.) His lawyer.
He is holding his agent responsible, lucky me!
He is holding his agent responsible, lucky me!
Contacting the DOI is the right move.
Unless you offered him Coventry as the only choice, you should be in the clear. Doesn't mean he won't make your life miserable.
I have had a few folks contact me over denied claims (mostly small ones but a few over $100k) but can't recall a pre-cert denial. In every case, including the 3 claims xs of $100k it took a lot of hand holding and in each of those cases the bulk of the claim was eventually paid.
A few have been miffed over small claims but only one decided to leave over the denial. They bought a Humana plan when they had a 90 day wait for preventive. They went in for a well check up about 60 days in and the claim (less than $300) was denied.
They called Humana first and filed a complaint. First I heard was when Humana wanted details of my proposal(s) and email about this.
I can't say if the 90 day wait came up in pre-sale or not, but in the end Humana (correctly) denied the claim for reimbursement but did allow those dollars to apply toward the deductible.
The client got pissed and cancelled their policy about a month later.
They lost more than I did.
Unless you offered him Coventry as the only choice, you should be in the clear. Doesn't mean he won't make your life miserable.
I have had a few folks contact me over denied claims (mostly small ones but a few over $100k) but can't recall a pre-cert denial. In every case, including the 3 claims xs of $100k it took a lot of hand holding and in each of those cases the bulk of the claim was eventually paid.
A few have been miffed over small claims but only one decided to leave over the denial. They bought a Humana plan when they had a 90 day wait for preventive. They went in for a well check up about 60 days in and the claim (less than $300) was denied.
They called Humana first and filed a complaint. First I heard was when Humana wanted details of my proposal(s) and email about this.
I can't say if the 90 day wait came up in pre-sale or not, but in the end Humana (correctly) denied the claim for reimbursement but did allow those dollars to apply toward the deductible.
The client got pissed and cancelled their policy about a month later.
They lost more than I did.
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Update!
Coventry denied the doctors appeal, stated he has to do therapy for 4 weeks. The therapy consists of strengthening exercises 2 hrs a day 3 days a week.
The doctor said if his suspicions are correct and it is a torn meniscus the exercises will be painful and of no help, he communicated this to Coventry and they said at the end of therapy if no better we will approve the MRI.
I am at a loss, the client just called and said he can't miss this much time from work and if they did the mri when he first went and if he needed surgery he would be walking and recovering now.
Now if he does the therapy and then has to have surgery it is setting him back 2 more months.
If he pays for the MRI out of pocket it will not be credited to the deductible, that has been verified.
Coventry denied the doctors appeal, stated he has to do therapy for 4 weeks. The therapy consists of strengthening exercises 2 hrs a day 3 days a week.
The doctor said if his suspicions are correct and it is a torn meniscus the exercises will be painful and of no help, he communicated this to Coventry and they said at the end of therapy if no better we will approve the MRI.
I am at a loss, the client just called and said he can't miss this much time from work and if they did the mri when he first went and if he needed surgery he would be walking and recovering now.
Now if he does the therapy and then has to have surgery it is setting him back 2 more months.
If he pays for the MRI out of pocket it will not be credited to the deductible, that has been verified.
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