Insurance claim denied!

Trailrun23 · ‎05-31-2022

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.

Mz iMac · ‎07-26-2014

Hope your sister or her husband files an appeal ASAP!

"Never argue with a fool. Onlookers may not be able to tell the difference."

Law08 · ‎08-14-2017

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

cindyNC · ‎08-01-2019

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

elated · ‎06-09-2010

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.

millieshops · ‎03-09-2010

@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.

Trailrun23 · ‎05-31-2022

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.

Icegoddess · ‎03-19-2010

@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.

Trailrun23 · ‎05-31-2022

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.