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]

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

[jensequitur]

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.

[LilMinnie]

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

[HVAC]

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

[yorkieville]

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

[HVAC]

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