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Insurance Question

Neeed advice from anyone that works for BCBS.

Over a year ago, my MS Specialist ordered 3 MRI's. I went to the same place I've gone for my previous MRI's. They claim they got the pre-certification from BCBS.

We recevied the Explanation of Benefits-BCBS stated they were paying for all 3 MRI's.

Months later, they sent us a new E.O.B. stating they weren't paying for one. Stating that only 2 are allowed in the State of IN. It's something new BCBS started.

My DH's Insurance Rep. has been fighting this for months, but getting nowhere.

So, is it legal for BCBS to originally give the pre-cert, then, later deny the claim?

TIA

Sheila





28 Comments Post a Comment
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I think your question should lie with the insurance commission of IN,
we are only patients who have MS............
we would have to be "up to date" on IN rules and such.

Good luck!
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Yes, Sarah, I realize we are only patients with MS-I've been a member of this forum for many years. But I do know there are members here who work for BCBS.

I've spoken with a member a few years back, just can't remember her name.

Thanks.
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no offense was intended, just saying fastest way to get an answer about precert then denial........was unaware of your forum status, I don't always go look people u before responding.  
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Sarah, I didn't take offense, and I truly hope you didn't take offense either.

Believe me, I'm not that kind of person.

I know, that my MS has made it difficult for me to word things the way I mean them. (:

Sheila
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198419_tn?1360245956
Hi Sheila,

I've had something similar to this happen to me. After round and round w/BCBS and getting no-where, I finally got to the bottom of it from the imaging facility.

Call them up. Give them your pre-cert numbers, tell them what you received from the EOB, and then ask them if there was something coded incorrectly on their end.

BCBS preapproved it, so they have to pay it. I'd put money on it, the imaging facility coded something wrong. Call their billing. And let us know what they say.

I had to go through one person who did not help at all. The 2nd one took care of it!
(((Hugs))
shell
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198419_tn?1360245956
And, so glad you asked this here, because oftentimes we can pass along what we've learned and cut through the red tape!
-shell
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3054080_tn?1358726456
Hi Yorkie,

My daughter works for a hospital as a patient advocate; the primary insurance company she deals with is BCBS.  I ran into a similar situation and my daughter gave me the same advice as Shell gave you (I have BCBS as well).  The only thing I would add is that my daughter recommended a three-way phone conversation with the hospital, insurance company, and me.  They got it straightened out.

Best of luck (and oh, I understand how frustating it can be!)

Hugs,

Minnie  :)
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Hi, Shell.

Rich has called and BCBS is standing by the "Two MRI's for one condition rule". The rule was put inot effect June 2011.

His Union Rep said the Provider should have known about the rule, and not done all 3 MRI's.

Rich even went over to my MS Specialist's office this morning, on the advice of his Union Rep and talked with the insurance person, and asked her if the doctor would change the diagnosis code on one MRI. She said it can't be changed. He asked her if she had anything in writing regarding the pre-approval request, and she told Rich that she was told that it didn't need pre-approval.

She said all she had were "Conversation Numbers" of the discussions, and she wouldn't give them to Rich.

She asked for his Union Reps phone number. He is in Detroit this week, and he took a letter regarding this mess, with him.

Rich is going over to Lakeshore Bone and Joint, this afternoon, the place I had my MRI"s and let them know, that we are working on it. And see if they will give him anything.

It's a mess, and somebody screwed up, and we may end up with the $3,264.00 bill. Which, on a fixed income, we cannot afford.

Sheila
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Hi, Minnie.

It's a big mess. BCBS instituted this new rule they are trying in Indiana. Two MRI's for one condition in a year.

We didn't know about it.

But, my DH's insurance Rep from Ford, where he retired, said the Provider, and the MS Specialist should have known about it.

As I told Shell, my MS Specialist's insurance person would not give my husband the "Conversation Numbers" she had with BCBS.

He said he found that to be suspicious. If I had been there, I would have asked her, "Why not? What are you hiding?"

So, he is going over to the Providers now, and talk with them.

In the meantime, his Insurance Rep is in Detroit this week, and he is fighting it.

I have an appt. with my MS Specialist on 10/24, and if this isn't settled by then, we are bringing it up with her.

Somebody screwed up.

Thanks for responding.

(((HUGS)))
  Sheila

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Hi, Shell. Hi Minnie.

Rich just got back from Lakeshore Bone & Joint. The Providers of my MRI's.

They told him that they don't have the pre-cert numbers, he needs to get them from my MS Specialists office.

So, since I have an appt. at a hospital 20 minutes from her office tomorrow, he is going to stop back in there and see her insurance person AGAIN.

What do you want to bet, she didn't even get the MRI's pre-certified?

Lakeshore said they are still working on it, too. I'm relieved they haven't turned the $3,264.00 over to a Collection Agency.

Sheila

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3054080_tn?1358726456
Yup, that's what it sounds like to me.  Good grief!  And yes, the Provider should have known about it!!!

My daughter has been such a Godsend throughout my quest for a diagnosis (still don't know what's wrong with me).  She warned me that although I shouldn't have to do it, I should follow up myself and make sure that anything ordered is pre-approved before it is done.  Also, if BCBS ever sends you a form to fill out and return, make sure you not only mail back the signed hard copy, fax it to them, too, and make sure you have your fax confirmation.

Not meaning to bad-mouth BCBS because I'm sure other insurance companies have issues, but I have a dear friend whose husband just passed away with bile duct cancer.  They had approved and paid some claims, and they actually TOOK THE MONEY BACK almost two years after they made the payment.  Yes, there is a clause where they can go back up to two years and "adjust" payments.  Luckily the hospital is giving her full assistance.  

I hope they get that mess straightened out soon.  Its bad enough being ill without having to go through all that!

BIG HUGE HUGS,
Minnie  :)
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198419_tn?1360245956
Yup - he'd not get anywhere from them for sure.

The facility would not have performed the imaging w/out the pre-cert. So, they have done something wrong, and they always want their money.

So, Rich will be able to move mountains with the imaging facility. They have those numbers honey - I know they do.
-Shell
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Yes, the Provider should have known it, and my DH's Insurance Rep wrote a scathing letter, defending us, stating that we are not the ones that file the claims. We provide the insurance info. to the doctors and clinics and it is their job to get tests authorized.

That is absolutely horrible that BCBS took the money back, after your friends husband died.

I'm glad the hospital is providing her assistance.

Thank you, I hope they get this mess straightened out pretty soon, too. It's really been a point of stress for me.

(((HUGS)))
  Sheila
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Hi, Shell.

It occured to me, that the Imaging Facility would definitley have gotten the pre-cert, because I've had MRI's done there before.

But they refused to give Rich the pre-cert numbers.

I think our best chance of getting this mess straightened out is the Insurance Rep from Ford.

And he is determined. He said this is just plain wrong.  He has access to all of it.

So, we have to wait to hear from him next week, when he gets back from Detroit.

~Sheila!~
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All BCBS's are independent of each other plus plans are not uniform in what they cover. You have to know the fine print in your contract so having the insurance rep. for your plan is your best bet.

If you end up having to pay it ask what the cash price is which is different from the insurance price. If they can give you that at the imaging place that is better.

I have to pay 1/3 for each MRI with my BCBSNC plan. Three MRIs which is what my Neurologist wanted was $2800 out of pocket so I did not have them.

Alex

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Hi, Alex.

Yes, we are aware that all BCBS's are independant of one another, and each plan is different.

Our plan is provided by the Ford Motor Co.-my husband retired from there.

The problem is that they changed a lot of the medical benefits in the last contract negotiation. And his Insurance Rep states that since we don't file our own claims, the providers know they are supposed to get pre-certs, and often pre-authorizations.

In this case, BCBS did give pre-certifications for all 3 MRI's. Someone at BCBS made a big mistake, and they are trying to make us pay for it.

Not going to happen.

Sheila
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When I worked for one BCBS I was told to deny a claim three times as it passed my desk hoping the person would give up and pay it. We usually paid on the third try. Just try not to get upset about it. To the insurance companies it is only business. They actually hope people will get upset and tired and give up. Hang in there.

Alex
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Hi, Alex.

Thank you. I'm really trying not to get upset about it. And I am really hoping my DH's Insurance Rep can get this resolved while he is in Detroit this week.

It's not fair, that the Prodvider got the pre-certs, did the MRI's and then BCBS changed their minds about paying for the 3rd MRI.

My DH said he got the impression from the Provider that they are not going to do anything about it.

Sheila
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They may not but like I said I had a manual the size of a telephone book with basically ways to wear down the the patient. I had to deny everything three times no matter what. Our goal was to make it so people were always on the phone or writing letters. You want to get people angry and frustrated and so sick of wasting there time they just pay the bill themselves.

No it is not fair. This is where your State's Insurance Commisioner's office can come in handy.

Hang in there. Many things in health care are not fair. I now have to pay $7,000 out of pocket in the next 36 months to a hospital cancer clinic which almost killed me. I also will owe for my cancer care at Duke which is higher in out of pocket costs. I am paying two hospitals at the same time but I am alive to do it.

Alex
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You're right, Alex. My daughter told me that she and the folks she talks to at BCBS know the dance so to speak. They have to go through the motions.

I get that it's business but good grief, hospitals have to hire someone to help make them pay and it is a waste of a lot of people's time and money.

Yorkie, I'm thinking of you and hope you can try to relax and that you get a positive resolution soon.

Hugs,
Minnie
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Alex has a good point - I just got the runaround from Aetna, because they refused to pay the cost of a blood test that they didn't regard as being 'necessary.'  $161 out of my pocket, but still extremely annoying.  I don't pay insurance to have my insurer decide whether something is medically necessary - that's what I pay my doctor for.
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Alex, the thing that I don't understand, is that BCBS gave the Provider, Lakeshore Bone & Joint, the pre-certification to do all 3 MRI's.

Then, BCBS came back later, and said they wouldn't pay for 1, because of the rule they made in June of 2011, allowing only 2 Radiolgy tests per condition.

My husband's Insurance Rep is in Detroit, MI, working on resolving this issue this week.

If he doesn't get it resolved, we will write to the Michigan State Insurance Commissioner's Office.

Another thing I don't understand, is why Lakeshore Bone & Joint refuses to give my husband the pre-certification numbers.

He suspects they knew they weren't supposed to do all 3 MRI's and did them anyway.

Now, that is really not fair that you have to pay $7,000. to a hospital cancer clinic that almost killed you.

A G.I. Doc at Cleveland Clinic ran so many tests on me, in 2 and 1/2 days, she just about did kill me.

Then, her Staff left me alone in a room in tachyarcdia and went home for the evening. The G.I. Doc was in another room, laughing with some guy.

You make a very good point, that you are alive to do it.

But health care in this country has become very dishonest, and in many cases, more about money, than health care.

Sheila
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Alex makes a very good point.

My son works for BCBS in IL, so he is of no help to us, since our BCBS is out of MI.

But, years ago, he told me, that most of the time, claims are being reviewed by college kids working "temp" jobs.

In this case though, someone screwed up, and we don't know if it was the Provider, or BCBS.

And we're not getting any answers.

And they're not getting any money.

Hopefully, my DH's Insurance Rep. will come home from Detroit, MI next week, and have resolved it.

Sheila
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Hi, Minnie.

Thank you-I'm trying very hard not to feel stressed about this situation. We've never come across it before.

It's very aggravating, since my husband and I are not the ones that file the claims. We provide his insurance information to the provider's and it is their responsibility to get the pre-certifications.

Now, I am nervous every time a doctor orders a test.

I'm having a lot of digestive issues, and I told my G.I. Doc's nurse what happened, so she has been extra careful in getting pre-certs and pre-authorizations.

I've got enough stress in my life right now. My older Yorkie died, 19 months ago to renal failure, and my younger one, was diagnosed in July.

I'm still grieving over losing my sweet Sydney. She made my MS bearable. And now, knowing I am going to lose my tiny Kia.....I don't need all of these so-called professionals making mistakes.

Sheila
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Hi, Minnie.

Thank you-I'm trying very hard not to feel stressed about this situation. We've never come across it before.

It's very aggravating, since my husband and I are not the ones that file the claims. We provide his insurance information to the provider's and it is their responsibility to get the pre-certifications.

Now, I am nervous every time a doctor orders a test.

I'm having a lot of digestive issues, and I told my G.I. Doc's nurse what happened, so she has been extra careful in getting pre-certs and pre-authorizations.

I've got enough stress in my life right now. My older Yorkie died, 19 months ago to renal failure, and my younger one, was diagnosed in July.

I'm still grieving over losing my sweet Sydney. She made my MS bearable. And now, knowing I am going to lose my tiny Kia.....I don't need all of these so-called professionals making mistakes.

Sheila
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338416_tn?1260996698
I think the money limits on insurance and what they're willing to pay has really hurt people.  That's one of the things the Affordable Care Act will fix.  No more caps on amounts of care, so that people won't have to pay out of pocket for their chemo.
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I agree 100%!

And one thing I really hate, is that insurance people are the ones that determine what my doctor is allowed to test.

Everyone in this country deserves the best medical care, and they shouldn't have to go into debt to get it.
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Well, this insurance mess hasn't gotten straightened out yet.

Rich's insurance Rep spoke with my MS Specialist's Insurance person, Megan, today, and she refused to give him the "Conversation Numbers' she claims to have had with BCBS.

So, Rich went back to Lakeshore Bone & Joint, and told them, that he needed the pre-certification numbers, if they wanted to get paid.

They insisted that the MS Specialist's office handled everything.

Does that make sense, that the Provider of the MRI's would not get the MRI's pre-certified?

If so, why did they take my inusrance information?

Sheila

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