Insurance Question

[yorkieville]

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

[yorkieville]

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

[HVAC]

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

[yorkieville]

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!~

[yorkieville]

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

[sllowe]

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

[LilMinnie]

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  :)