Really discouraged by insurance company

[janeinnc 0]

I was banded on 3/31 and have done fairly well sticking to the program, lost 30 lbs., etc. I did have to have a port revision several weeks ago due to my port flipped. But, what I am really discouraged about is I went through the usual routine of testing, pre-authorization, etc. and thought everything was ok until Monday, when I received a notice that my claim was denied with BCBS. AUGHHH! How can they do this? I have a pre-authorization approval, but, they are saying that obesity surgery is not part of my plan. I have asked that they reconsider the additional diagnosis that was submitted by my physician (GERD, Hypertension, etc.) that the surgery was to also correct (and seems to be doing so). Anyone else have this issue?:thumbup:

[Beachbunny 5]

what Bcbs do you have and is it a ppo or hmo?

[tinksmom 0]

Actually I just got a similar notice where it says the surgery was not covered, nor the hernia reapair, yet they were happy to cover the anaesthesiologist. It said services weren't covered after I had specifically gone to both BCBS and HRand confirmed there was no exclusion. When I read further it said that the surgery was done at a non-covered facility and by a non-covered surgeon. Since I know this to be untrue I looked at who billed and it was a name I had never seen...just a corporate name. I am assuming that, since I have not heard from the doctor...or the sugical center where I go for other procedures and know is covered...that it is a mistake in billing codes. If not, and I really do owe this amount, I will just have to make payments each month. I mean, we agreed and signed for a price to be billed to insurer and that is what I owe, so it will be just one more bill. They can hardly force me to remove the band. If I end up paying for fills - so be it. BCBS payed all my pre-op visits so I think I'll let the fight it out and rebill. I have other fish to fry. By the time it is settled, my health will be improved and I should be back to work.

[tinksmom 0]

Just got off the phone with BCBS and then anesthesioligist office. (I have to psyche myself up to deal with this stuff so it took me a while.) These notices are so confusing. The first thing that happened was that apprently an assistant surgeon was brought in. Why I do not know, since there were no problems with my surgery. I never saw or met this person and still have no idea of his/her name. But ins was billed almost $8000 for the services, on top of my doctor's fee. The problem stemmed from the fact that this doctor was not a BCBS surgeon so the bill was rejected. On researching it, the customer service rep found an agreement with that doctor that he would accept BCBS max..and that had alreeady been paid. So I owe a small copay of $50 or so...which I can pay when and if I ever learn who to pay. The second problem was that the anesthesiology bill was also rejected, although the facility and doctor had been paid. This is obviously absurd...the same people had been paid 3 weeks later for a carpal tunnel surgery so they are obviously in network. Turn out...and the rep said this is common...their claim had been submitted with the wrong code...and did not match the physician's or surgical center's. The code must be not for obesity but for morbid obesity. I called and told them what to look for and they will resubmit. Everyone else is fairly happy. Whew! The moral of the story is to call your insurance company! Rep said they almost never deny after approval without a good explaination. They will explain all the claims for that procedure and find what is going on. The guy I talked to was wonderful...took over half an hour to work things out for me.

[spoiltmom 44]

I used to do medical billing. You need to send in a formal appeal letter and attach a copy of your pre authorization approval.