topic Re: Insurance claim denied! in Wellness

Insurance claim denied!

Trailrun23 — Tue, 20 Sep 2022 01:01:09 GMT

My BIL just went in for a hernia repair two weeks ago ; it was day surgery to correct some scar tissue buildup. He was put under general anesthesia. He is 75. His heart rate fell to 13 bpm and would not go back up. Surgeon asked my sister for permission to put in a pacemaker. She said okay. Today she called me and said her Medicare plan denied the claim, twice, because it wasn't preauthorized. How can you get something like that preauthorized when it is an emergency? Wish she lived closer so I could have been there at the hospital. He is doing fine, but dealing with BCBS is going to be a pain.

Re: Insurance claim denied!

Mz iMac — Tue, 20 Sep 2022 01:06:53 GMT

Hope your sister or her husband files an appeal ASAP!

Re: Insurance claim denied!

Law08 — Tue, 20 Sep 2022 01:10:36 GMT

Go to Medicare.gov and search for "Appeal". Also have your sister call BCBS to appeal the denial. I wish them the best!

Re: Insurance claim denied!

cindyNC — Tue, 20 Sep 2022 01:12:08 GMT

Can she call Medicare directly? the number on the back of the card.

Re: Insurance claim denied!

elated — Tue, 20 Sep 2022 01:14:57 GMT

This is the games they play with people. I had a mammogram when I had Aetna Medicare. They kept refusing to pay for the radiologist. I wrote a letter to their billing and corporate office. I told them if they continued to deny what was an annual mammogram to be fully covered, I would contact the Attorney General. I never heard back and the billing was resolved. I tried so many times going through proper channels, it was exhausting.

Tell them to try alternate avenues to get a resolution. They just don't care unless you push them to the edge of no return. Have that surgeon write a letter and go forward. I wish them the best.

Re: Insurance claim denied!

millieshops — Tue, 20 Sep 2022 01:39:01 GMT

@Trailrun23 Every plan is different and they differ from state to state. Do contact the insurer!

After I had surgery a few months back, lo and behold I got a bill for nearly $5000 for anesthesia because the claim was denied.

I called my insurer. Took no time on the first call, but I got an answer I didn't like so I called again. Got another agent with a slightly different answer, but I still had that bill.

I slept on it and called a third time the next morning. By now I had read through page after page in the contract and could find not one message I had to call. The hospital and the each doctor had to. The first 2 reps tried to convince me I could have signed a promise to pay among all the papers shoved in front of me prior to surgery.

The anesthesia had been denied because it wasn't preapproved. Weird, because they paid the surgeon the day of the surgery. Seems if they approve the surgery, they should automatically approve anesthesia, but no.

With the help of the third rep, the anesthesiologist's office learned they had created the problem. I have yet to see notice they have been paid, but my record shows I owe nothing.

Yes, it took time and angst, but I got to keep my money.

Re: Insurance claim denied!

Trailrun23 — Tue, 20 Sep 2022 01:44:06 GMT

My sister contacted the surgeon's office but it sounds like the woman who handles insurance claims isn't very helpful. The surgeon sent the appeal letter according to the office but my sister said BCBS says they never got it. I would ask for a copy of the appeals letter. The usual hoops to jump through. I will talk to her tomorrow and see if she has any other info yet.. When I had surgery a few years ago, the billing office, claim dept, and payment office were in three different states. It took me months to get everthing settled correctly.That was Aetna. Thanks for all the suggestions! She is quite upset but BIL takes everything in stride...very laidback....thank goodness.

Re: Insurance claim denied!

Icegoddess — Tue, 20 Sep 2022 01:55:05 GMT

@elated wrote:
This is the games they play with people. I had a mammogram when I had Aetna Medicare. They kept refusing to pay for the radiologist. I wrote a letter to their billing and corporate office. I told them if they continued to deny what was an annual mammogram to be fully covered, I would contact the Attorney General. I never heard back and the billing was resolved. I tried so many times going through proper channels, it was exhausting.

Tell them to try alternate avenues to get a resolution. They just don't care unless you push them to the edge of no return. Have that surgeon write a letter and go forward. I wish them the best.

@elated I'm not on medicare yet, but I had a similar experience with BCBS. Tried to claim the radiologist who read the Mammo wasn't in-network. When I called and told them I had no say in that, the nice lady agreed with me and put it through.

However, can't do that anymore. You can't appeal via phone. You have to file it. I ran into that when they wouldn't pay for my pap smear, wrong lab. So, even if you go to an in-network gyno, you have to have them send it to an in-network lab. Or, code it as such. My gyno told me at my visit last month that she had actually given the smear to some of her clients to take to the correct lab, but luckily for me they just had to code it as if it went to Quest.

And we're expected to know these things. I tried calling BCBS to make sure I was going to an in-network place for my mammogram, and they couldn't even tell me. The CS person could only see the same thing I had access to via their web portal. A lot of help they were.

Re: Insurance claim denied!

Trailrun23 — Tue, 20 Sep 2022 02:10:24 GMT

I will ask her tomorrow if she has called Medicare. I think since he has an advantage plan she may have only called BCBS; I think that is who sent the denial letter.

Re: Insurance claim denied!

ellaphant — Tue, 20 Sep 2022 02:14:58 GMT

American ' health care' is shameful.

Re: Insurance claim denied!

drizzellla — Tue, 20 Sep 2022 02:18:32 GMT

@Trailrun23 Did the Doctor's office code the procedure correctly?

Sometimes the claim is rejected because it is coded incorrectly.

Re: Insurance claim denied!

Tinkrbl44 — Tue, 20 Sep 2022 02:19:23 GMT

@Trailrun23

This is so wrong ..... and I'm sorry this is happening in your family.

As others have stated, this denial needs to be appealed. Disputing anything with an insurance claim denial can be frustrating .... but it can be reversed. I personally disputed a life insurance application denial, back when I was in another career, in another lifetime. The denial was re-evaluated when I provided additional information, and the decision reversed.

Sometimes, being determined and calling repeatedly to move the appeals process along can ... sometimes ... work miracles.

My grandmother used to remind us ... the squeaky wheel gets the grease.

Re: Insurance claim denied!

Trailrun23 — Tue, 20 Sep 2022 02:20:50 GMT

I know it is all about the code. Am sure they will double check it. I may have to hop on my broom and help my sister. It's an hour's drive, but faster on my broom!

Re: Insurance claim denied!

Kachina624 — Tue, 20 Sep 2022 02:39:23 GMT

@Trailrun23 If things get ugly with BCBS, remember there is a state regulatory board/agency to which they can appeal.

Re: Insurance claim denied!

ScrapHappy — Tue, 20 Sep 2022 11:10:58 GMT

My daughter's speech therapy was denied by BCBS, they're the worst. She was born very premature, three months early weighing 1.7 pounds. She wasn't breathing when I had an emergency C-section and was intubated and life flighted to UCSF. BCBS denied speech therapy because they said being born premature wasn't a medical condition. I had to appeal, lots of paperwork and statements from doctors, speech therapists, etc. BCBS denied it again. Took case to lawyer and was told we had an excellent case, that insurance companies will deny, deny, deny because they don't think you're going to put in the effort to get it covered.

Re: Insurance claim denied!

SeaMaiden — Tue, 20 Sep 2022 12:08:53 GMT

@millieshops wrote:
@Trailrun23 Every plan is different and they differ from state to state. Do contact the insurer!

After I had surgery a few months back, lo and behold I got a bill for nearly $5000 for anesthesia because the claim was denied.

I called my insurer. Took no time on the first call, but I got an answer I didn't like so I called again. Got another agent with a slightly different answer, but I still had that bill.

I slept on it and called a third time the next morning. By now I had read through page after page in the contract and could find not one message I had to call. The hospital and the each doctor had to. The first 2 reps tried to convince me I could have signed a promise to pay among all the papers shoved in front of me prior to surgery.

The anesthesia had been denied because it wasn't preapproved. Weird, because they paid the surgeon the day of the surgery. Seems if they approve the surgery, they should automatically approve anesthesia, but no.

With the help of the third rep, the anesthesiologist's office learned they had created the problem. I have yet to see notice they have been paid, but my record shows I owe nothing.

Yes, it took time and angst, but I got to keep my money.

Did you verify the ENTIRE procedure was approved first and that ALL involved were in network?

Re: Insurance claim denied!

CelticCrafter — Tue, 20 Sep 2022 13:10:19 GMT

@millieshops wrote:
@Trailrun23 Every plan is different and they differ from state to state. Do contact the insurer!

After I had surgery a few months back, lo and behold I got a bill for nearly $5000 for anesthesia because the claim was denied.

I called my insurer. Took no time on the first call, but I got an answer I didn't like so I called again. Got another agent with a slightly different answer, but I still had that bill.

I slept on it and called a third time the next morning. By now I had read through page after page in the contract and could find not one message I had to call. The hospital and the each doctor had to. The first 2 reps tried to convince me I could have signed a promise to pay among all the papers shoved in front of me prior to surgery.

The anesthesia had been denied because it wasn't preapproved. Weird, because they paid the surgeon the day of the surgery. Seems if they approve the surgery, they should automatically approve anesthesia, but no.

With the help of the third rep, the anesthesiologist's office learned they had created the problem. I have yet to see notice they have been paid, but my record shows I owe nothing.

Yes, it took time and angst, but I got to keep my money.

What was the surgeon supposed to do, knock you in the head?

Sometimes the denials are so ridiculous you have to wonder if they even bother to read anything.

The one that gets me is the lab charging to insert the needle to draw blood. Yes, it's covered but the alternative would be bringing a bucket of blood for them to test?

Re: Insurance claim denied!

skatting44 — Tue, 20 Sep 2022 14:01:04 GMT

@Trailrun23

Is there a coding error from the hospital . His Hr had to be in the 30's . Maybe the surgeon , did not indicate this was a medical emergency . The Cardiologist may not have documented clearly .

Re: Insurance claim denied!

deeva — Tue, 20 Sep 2022 14:11:31 GMT

That's one of the problems with Medicare Advantage plans. They deny a lot of necessary procedures.
I'm dealing with this with my 87 year old aunt.

Re: Insurance claim denied!

patbz — Wed, 21 Sep 2022 02:05:23 GMT

DH has had many health challenges over the years but one of the worst was when he had a quadruple bypass and bcbs denied the anethesiologist. When I saw that I laughed (what was he supposed to do...bite down on a stick?). The denial was so ridiculous that I didn't jump to have it corrected. Surprise; next cycle it was corrected. Over the last 35 years I'm sure bcbs has paid out close to $2 million for DH so it all works out in the end and only once did I have to actively protest to them. That time I had to make an appointment at bcbs headquarters in Phoenix ( the dispute was over an emergency that started at our local rural in network hospital, an emergency 150 MI helicopter ride and 2 weeks in ICU at Mayo Clinic; $450,000 " out of network" bill). There was an armed guard sitting right outside office (door open!!!)were I had appointment with insurance tech and her supervisor we won; our part if bill was $10,000.