Problem with Medical claim

[yorkieville]

I saw a Gyne at University of Chicago Hospital. I live in NW IN. She is in my BCBS PPO. My plan does not pay office calls, but I get a reduced fee because they have an 'amount allowed'. My insurance info was requested the day I made the appt. I rec'd a copy of the E.O.B. and the claim was submitted as $210.00 for hospital services and $509.00 for Medical Care. After numerous phone calls we found out that the $210.00 was a "use of office" charge, and BCBS denied it because it is not a covered benefit. (I've never even heard of such a charge.) They also denied the $509.00 stating this is not a covered benefit when performed in this setting. I am not getting any help from BCBS and the Gyne's finance person does not return my calls. $719.00 for a pelvic/rectal exam and for the Gyne to order a test is outrageous. My DH is retired and we live on a fixed income. Every other doctor's office I have ever been to has called BCBS for a 'Predetermination of Benefits" and contacted me and advised me when something is not covered and advised me of what will be my responsibility. Do you have any suggestions for me?

[yorkieville]

I finally got some resolution to the claim. Our Benefits Rep from Ford in Chicago, where my DH retired, was persistent and kept talking to different people at BCBS in MI. Finally, this morning, he spoke to someone and they handled it. They called University of Chicago, and they got our PPO discount; reduced the doctors fee from $509.00 to $107.00. They weren't able to do anything about the $210.00 "use of office" charge because it is not a covered benefit, but our Rep said he would refuse to pay it, based on the fact that I was not told there would be anything other than the doctors fee. He said another doctor had tried to charge him that fee, and he refused to pay it, and he never heard another word about it. He said he feels it is a way they try to get some of their money back they lose on the PPO patients. He said they may threaten to take me to court, and he said to tell them I'll counter-sue for fraudulent charges. My son works for BCBS of Illinois and he said BCBS of MI is one of the worst ones to deal with to get anything resolved. When I told my doctors here in Indiana about the charges at U of C Hospital, they were outraged and told me to get our benefits rep involved. They felt the 'use of office' charge was ridiculous. Thanks for answering my post. It's funny, I've never had this type of problem with a doctor or hospital and my insurance plan. I was even referred to a Neurologist at Cleveland Clinic a few weeks ago; absolutely no problem with the claim.
What I don't understand is BCBS's indifference to resolving this immediately, as it was not costing them any money. We pay our doctors fees, we just get the PPO discount.

[hea]

You have one of those fun plans.  I am being sarcastic about that.  My parents' have one similar and it confuses me.  I work for a Blue Cross Plan unfortunately in a different state and we do not offer anything like it so I cannot help you or them with it which is very frustrating when they call with questions.  The advice I give them is to go directly to the dr's office and speak with their billing office.  See if they can get Blue Cross to explain everything to them.  Sometimes things can get rebilled under different codes so that it will be covered.  It's not being dishonest, it's just that it was not billed properly based on how your plan works.   If that does not work, you may have to go to BlueCross and have them explain everything to you.  You can file a grievance against them as well.  My parents are in Michigan. Blue Cross there does not have the best reputation for wanting to pay.  I do not know how Chicago's is.  If I could give you better advice I would.  I hope everything works out for you.  If, ultimately, Blue Cross does not pay, you can sometimes negotiate prices with the dr's offices but you should not have to.  Everything should have been discussed prior.  Particularly since they had the information in advance.