Approved..had Surgery..now Insurance Is Trying Not To Pay!

[CATHY1102 0]

HI;

I am wondering if this has happened to anyone else, and if so, what was the out come.

I have BCBS of Illinois. I work so diligently, to provide the insurance company with all requested information. I finally got the approval letter from the which specifically named, using the CPT codes for the Lap band procedure..approving it. I do not know if someone up there messed up or what..but that is really not my problem. I was so happy to get approved I cried. I had waited 2yrs.

So, I had my surgery 7/5/2007. BCBS has not yet paid. My doctors office received a call last week saying that they were not going to pay for it!! I could have NEVER afforded this by myself. We have a copy of the approval letter, and also the persons name that gave the verbal approval over the phone to my Dr when they gave them the surgery date.

We are writing to the Comissioner of Insurance.

Does anyone know anything about this? I am worried sick.

thanks.

[Kat817 19]

Make sure you send the insurance company a copy of the letter going to the insurance commision---also individually send them to whoever signed off on the approval, and the woman the Dr.'s office spoke to. It is my bet that it will soon be paid after that. Providing your codes match....they approved it. IF your Dr, somehow changed procedures, or billed for the wrong one, then in the end I would let them eat the cost----you did your part.

As a last resort, consult an attorney----you went into it in good faith on their ok.

Sorry you are having to deal with someone elses screw up!!!

Kat

[2bthinagn 3]

I agree with what was just said. Also, check to see if you have a Benefits person with your company. You may also have legal benefits through your company. Not a company attorney but a referral to an attorney. I have used that through my husband legal service at work. They sent 1 letter and it was taken care of. I cant believe they would refuse after you have it in writing that they would pay. I think you have the upper hand here.

[Kat817 19]

Oh good point! Let HR at your employer or place of insurance get in on it! They very well might just turn it over to an attorney for representation.

Kat

[CATHY1102 0]

thank you both!! I will definitely contact HR..and an attorney if I have too.

[QTkidsmom 0]

Have you called your carrier directly to ask why they have not paid the claim? I work in managed care, have for many years. Typically, when this sort of thing happens it is because the provider failed to send them requested records.

Once the procedure is approved, they cannot legally delay paying the claim unless they have a good reason. As I said, this is usually that the provider either failed to supply requested information, or as was suggested in a previous post, billed incorrectly. Either way, the provider will need to rectify the situation.

Only other thing that I can think of is that there was a some sort of contingency on your authorization. However, it would need to state that on your approval letter. Other than that, you acted on good faith and ultimately, they will have to pay up if the procedure done, was what was authorized.

God Bless!

[FinallyFree 1]

Cathy, the same thing happened to me. I called the hospital and insurance company, it turned out to be what QTkidsmom described.

The insurance company was waiting for paperwork, and according to both the hospital and insurance co. this can take up to 3 weeks before being received.

Don't freak out, especially since you have your approval letter. Be nice on the phone, it will be ok.

[Wheetsin 714]

At the point that they denied the claim you should have received an EoB and it should have a clearly stated reason why it was not covered.

For example, I used an in-network physician a few weeks ago, but when I received my EoB it stated:

Claim denied because: in-network physician not used.

I got mine taken care of, but the point is -- have you received your statement, and what was the reason? If you have not received it, call and ask them why it was denied. I personally would start here vs. escalating.

I also had a hard time getting my insurance co to cover the anesthesia portion of my surgery. Stupid, huh? Come to find out there was a conflict in the way that billing is submitted between anesthesiologists and nurse anesthetists. I nagged while they fought it out between them, and they eventually paid.

Insurance companies really aren't looking to rip people off, so if it were me I would give them a good faith opportunity to explain the situation. Once you know WHY it was denied, you can move forward accordingly.

Also, review your letter of approval. Most have a clause to the effect of, "...this does not guarantee payment/approval."

[jencys 2]

I worked in the prior authorization department about 10 years ago. One day someone called in to check the authorization on an out of state surgery. Well I read through the notes, saw it stated it was approved and told the nurse over the phone. The next day I was called into my boss' office because I had given out the incorrect information and the surgery has already been performed. Yup almost lost my job, yup they had to pay for my error... So don't get stressed about it, you have a letter from them with the approval. They can't go back now