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, 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

[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.

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

[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  :)

[sllowe]

And, so glad you asked this here, because oftentimes we can pass along what we've learned and cut through the red tape!
-shell

[sllowe]

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