BCBSNC - Claim Denied After Approval?

[heymargo 0]

In January, I called my insurance company and asked if WLS was covered. I was told yes as long as I met the criteria - co-morbidities, psych eval, meetings with nutritionist, 5 years or more over 100lbs overweight, bmi, etc. I did what I was supposed to do and received the approval from the insurance company and 3 weeks later had my surgery. Last week, I received a statement from BCBSNC showing claims submitted and subsequently DENIED for costs of over $100K. They denied the surgeon's claims and they denied the hospital's claims. A few days later, I received another of the same denial letters this time stating they paid $5K of the surgeon's fees and $58K of the hospital's fee and in another letter, a bill from the hospital for $27K. Um...I was told I only had to pay the deductible and the 90/10 co-insurance that would not exceed $1500. I don't want to call my insurance company because I'm scared of what they'll say. Does anyone know what this is all about? Am I going to have to call an attorney? I don't have $37K!!! If I did, I would have paid for the surgery in cash (it would have only been $12.5K) Can anyone help?!?

Thanks,

Margo:eek:

[tntbelt 1]

I have no experience in this area but why did it cost 100K? I am still in the approval process but I was told my surgery would be 17-18K. I know 10 was for the hospital and 5 for the surgeon. I am guessing it was denied because it exceeded the amount that they would cover for the surgery. Do you have an EOB from the insurance it should say on it.

[Beachbunny 5]

In January, I called my insurance company and asked if WLS was covered. I was told yes as long as I met the criteria - co-morbidities, psych eval, meetings with nutritionist, 5 years or more over 100lbs overweight, bmi, etc. I did what I was supposed to do and received the approval from the insurance company and 3 weeks later had my surgery. Last week, I received a statement from BCBSNC showing claims submitted and subsequently DENIED for costs of over $100K. They denied the surgeon's claims and they denied the hospital's claims. A few days later, I received another of the same denial letters this time stating they paid $5K of the surgeon's fees and $58K of the hospital's fee and in another letter, a bill from the hospital for $27K. Um...I was told I only had to pay the deductible and the 90/10 co-insurance that would not exceed $1500. I don't want to call my insurance company because I'm scared of what they'll say. Does anyone know what this is all about? Am I going to have to call an attorney? I don't have $37K!!! If I did, I would have paid for the surgery in cash (it would have only been $12.5K) Can anyone help?!?

Thanks,

Margo:eek:

I have BCBS ins of Georgia, same 90/10 . If the hospital was in network they cannot , i say cannot bill you more than your 10 % of what the insurance company deams usual and customary. If the hospital proceeds to bill you the remainder and they are in network , call BCBS and the insurance commisioner where you live.

[happygirl65 5]

In January, I called my insurance company and asked if WLS was covered. I was told yes as long as I met the criteria - co-morbidities, psych eval, meetings with nutritionist, 5 years or more over 100lbs overweight, bmi, etc. I did what I was supposed to do and received the approval from the insurance company and 3 weeks later had my surgery. Last week, I received a statement from BCBSNC showing claims submitted and subsequently DENIED for costs of over $100K. They denied the surgeon's claims and they denied the hospital's claims. A few days later, I received another of the same denial letters this time stating they paid $5K of the surgeon's fees and $58K of the hospital's fee and in another letter, a bill from the hospital for $27K. Um...I was told I only had to pay the deductible and the 90/10 co-insurance that would not exceed $1500. I don't want to call my insurance company because I'm scared of what they'll say. Does anyone know what this is all about? Am I going to have to call an attorney? I don't have $37K!!! If I did, I would have paid for the surgery in cash (it would have only been $12.5K) Can anyone help?!?

Thanks,

Margo:eek:

Hey! Not sure if you have already gotten all of this figured out yet or not...but I see this all the time with my insurance (BCBSAZ) Basically the doctors send a bill to the insurance company...it is usually an inflated rate...the insurance company says....uh...sorry the negotiated rate is this...and this is how much we will pay you. So they pay the lesser amount (that has previously agreed to in their contracts) and then they send out a statement to the insured (you) showing you exactly what happened....ie...how much was billed...how much was paid....what the difference is....these statements can be kind of scary because it kind of looks like they expect you to pay the rest...but really you should be paying whatever your deductible plus cost share and any "access fee" that is spelled out in your plan for surgery and the rest has to be adjusted off by the hospital.

If you are afraid to call the insurance company, just call your hospital billing department, they can probably help explain it a little better.

I have not had surgery but have had plenty of regular doctor visits and this is always what happens...just got one for my daughters broken arm.... $800 the doctor charged to the insurance...the insurance paid 165.00 I paid my co pay...and the doctors office has to then go back and credit the remaining balance because they agreed to take a "discounted rate" from the insurance company. Happens ALL the time. :smile2: I am sure everything will be fine. If they had truly decided to deny it, they would have not paid anything out at all and that would be an entirely different story.

Hope that helps and wasn't too convoluted or confusing.

Good luck with everything!

[lukesdiesel 2]

Ya what they sent you was probably just a statement and not an actual bill.

Luke

[ylgdsire 0]

In January, I called my insurance company and asked if WLS was covered. I was told yes as long as I met the criteria - co-morbidities, psych eval, meetings with nutritionist, 5 years or more over 100lbs overweight, bmi, etc. I did what I was supposed to do and received the approval from the insurance company and 3 weeks later had my surgery. Last week, I received a statement from BCBSNC showing claims submitted and subsequently DENIED for costs of over $100K. They denied the surgeon's claims and they denied the hospital's claims. A few days later, I received another of the same denial letters this time stating they paid $5K of the surgeon's fees and $58K of the hospital's fee and in another letter, a bill from the hospital for $27K. Um...I was told I only had to pay the deductible and the 90/10 co-insurance that would not exceed $1500. I don't want to call my insurance company because I'm scared of what they'll say. Does anyone know what this is all about? Am I going to have to call an attorney? I don't have $37K!!! If I did, I would have paid for the surgery in cash (it would have only been $12.5K) Can anyone help?!?

Thanks,

Margo:eek:

I have BCBSNC also, & they have a website where u can see the claim & if its processed already they will show what the amount that was billed & The amount that was paid by BCBSNC. Also, how long did u wait to be approved? I have been waiting 40 days now & no response. What should I do?