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My doctor ordered a ct scan. Hopital obtained pre-certification of wrong type of ct scan. Insurance denied claim. Who pays?

Sidney, OH |

Insuranc pre-approved head and neck ct scan. Proceedure done was a temporal bone ct scan per the dr.s order. Insurance approved head and neck. denied temporal bone. Insurance says it is hospital responsibility, hospital says it is my responsibility to pay.

Attorney Answers 2


If the doctor ordered X and the hospital performed Y, then you should complain to risk management. Have the medical records in hand to demonstrate what the physician ordered and then what was actually performed. have documentation from your insurance company of the problem so that the cost can be illustrated. Prepare a cover letter (very polite) and send copies of these things. make it nice & professional. Send it certified mail with return receipt requested. Call ahead to the hospital and get the name of the risk manager so that you can send the letter to the right person.

Eventually you will have a conversation with someone in risk management. My guess is that the charge might get adjusted off.

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Something happened between the hospital and the insurance company that is not your fault. If the risk manager is not helpful then try having your doctor write an explanation saying that the temporal bone ct was supposed to be ordered, NOT the head and neck scan. As long as it was ordered, as evidence by your medical chart, your insurance company should pay for it.

Good luck.

DISCLAIMER: David J. McCormick is licensed to practice law in the State of Wisconsin and this answer is being provided for informational purposes only because the laws of your jurisdiction may differ. This answer based on general legal principles and is not intended for the purpose of providing specific legal advice or opinions. Under no circumstances does this answer constitute the establishment of an attorney-client relationship.

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