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

[LilMinnie]

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  :)

[yorkieville]

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

[yorkieville]

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

[yorkieville]

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

[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  :)

[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