Any skills dealing with insurance companies?

[huckasoreass]

Last spring, I waited an extra month to get ACL reconstruction so I could do it at a preferred provider hospital for my insurance company. I made the mistake of not looking deeply into my coverage (which in the end, wouldn't really have helped). As I understood it, I was on a basic Blue Shield of California plan, and the doc took Blue Shield at this particular surgery center.

I got the surgery, then had some issues with insurance that I thought were resolved. After a few calls, the surgery center said Blue Shield would be picking up 70% of the tab. Not great, especially after my $2,000 deductible. But that's what I was stuck with.

A month and a half ago, after quite a bit of physical therapy, I get a letter from Blue Shield that they were sending to the PT hospital, saying they had paid for PT for the month of July but now wanted a refund for the entire amount, because "based on a medical consultant's review, this procedure was not described in documentation submitted." After several calls, one of which was made by my therapist who is tired of dealing with insurance companies trying to stick it to the little guy, little was resolved, other than Blue Shield saying they're not sure why that was sent.

Then a couple of days ago I receive a bill from the surgery center. I've already paid a separate $2,800 for anesthesia and assistant surgeon out of pocket. But this newest bill is for nearly $11,000, minus a whopping $1,400 that Blue Shield has so generously paid. After several more calls, I find the surgery center has done all they can, and that Blue Shield claims there's a clause in my plan that allows for a maximum payout of $500 on a claim/day. You know, that small print, line 45 of page 67 of their coverage plan? So, in essence, if you had a $100,000 surgery one day for who knows what, Blue Shield is willing to throw down a big old $500 towards it.

The woman at Blue Shield told me today that it's actually a good plan. Yeah, as long as you NEVER GET HURT AND NEVER GO TO THE HOSPITAL. Who gets any substantial care for $500 today? To me, it's ridiculous. I've put thousands of dollars into their hands over the years for such an instance, and now they find their escape clause, one that to me has no merit. A $500 maximum payout?

Anyway, I'm going to file a grievance in a matter of days, but I wanted to see if anyone has had any experience with this type of thing. Basically, in the end, I may end up getting stuck paying roughly $12,000 out of pocket, while my wonderful Blue Shield of California protectors weasel out by chipping in $1,400. Great. Guess my newborn son will have to endure the 48 degree temps in his room and nothing but breast milk, bread and water for the next ten years. Thanks a lot, Blue Shield. Appreciate it.

[keksie]

I know nothing about the American insurance thingies.. but man, that sucks big time. Insurance companies are always bitch to deal with. I'm sure someone here can give you some good advice, personally I can't but I hope you get this resolved.

[runethechamp]

Wow, that sucks. That $500 thing souds pretty incredible, can't believe it's true. I had some issues a year ago regarding a catscan Blue Shield didn't want to approve, but my doctor fixed it for me. But that thing was $5k, for about an hour or two worth of work. $500 pr/day, WTF is that?

[lemon boy]

getting a lawyer to fuck BC/BS in this situation = worth every fucking penny.

[shmoesmith]

T Blue Shield claims there's a clause in my plan that allows for a maximum payout of $500 on a claim/day. You know, that small print, line 45 of page 67 of their coverage plan? So, in essence, if you had a $100,000 surgery one day for who knows what, Blue Shield is willing to throw down a big old $500 towards it.

Those clauses are usually for outpatient shit...Physical therapy, going for follow-up treatment etc. There are two parts to medical insurance. The part that should be covering you is called major medical. There should be a deductible and a max-out of pocket/year(assuming you are on a 70/30 plan, which it sounds like). I'm not licensed in CA(in other states though)it sounds like they are screwing you, or that someone is reading the wrong section of your insurance paperwork and denying it based on that.

Edit: what is the EXACT plan you are on. While I'm not licensed in CA, most states insurance laws are the same (infact you dont have to take a test for each state, only one state and pay the fees in each additional state you want licensing in). I'll take a quick look at the plan to see what they are talking about.

[schuss]

snip

That's BS. Definitely get a lawyer and re-read your contract. No way they can get that attached to a policy with a 2K deductible. Sadly I work in the wrong part of insurance, but there's not a doubt in my mind that someone is a bit overzealous in interpreting one clause.

[avacadotoast]

That limit doesn't sound like anything you'd find in a group plan, is this an individual policy (you only)? Even if it is I've never seen such a drastic 'one-day' limit like that. If this is a group policy, which plan do you have? I'll do some research.

Read your 'Summary of Benefits' or 'Explanation of Coverage' and look for a reference to said one day limit. Let me know what it says.

Oh, I just found a BCBS Summary of Benefits (they're our competition so we monitor their stuff) for one of their PPOs. This one says for Outpatient Surgery they cover 75% in-network and out-of-network is capped at $380 per day for the facility charges. Physician charges are similar (I won't go into details). Sounds like they could be paying this as an out-of-network claim - is this possible?

As far as the PT goes, it sounds like they need some documentation from your doctor. If that's been done get a copy of what was sent and tell BCBS you want to appeal. Read what your doctors office sent and discuss this w/ BCBS and find out YOURSELF if everything BCBS needs was included - you'd be surprised at how often Doctors offices submit things incorrectly and throw their arms up in the air like they can't do anything

[huckasoreass]

Edit: what is the EXACT plan you are on. While I'm not licensed in CA, most states insurance laws are the same (infact you dont have to take a test for each state, only one state and pay the fees in each additional state you want licensing in). I'll take a quick look at the plan to see what they are talking about.

It's called the Shield Spectrum PPO Plan 2000 (but right now it feels like the Pleasure Vibe 2000 rammed into the wrong place). Thanks for any input you have. The plan states subscriber co-pay of 30% for both Surgical Benefits and Reconstructive Surgery, and I'm struggling to find the $500 cap clause (which is just what they want, it seems--hidden so you don't see it). I really think it was an outpatient thing, so perhaps the surgery center's wording was wrong on their statements? I don't know...

[shmoesmith]

By your description, that's the one that I thought it would be. Note, even services with all providers, there is a maximum coinsurance(this is the part you have to pay beyond the deductible)of $7,000/yr (only $4500/yr with prefered providers). Meaning that the MAX they should be able to go after you for in any given year would be 9K(2Kdeductible+max coinsurance ammount..unless, of course you go over the lifetime max of 6million)..Now this is assuming it is a COVERED benefit. The clauses I have listed below show that your operation may NOT have been a covered benefit

Now, there are these two clauses that may cause you problems
"2 These copayments do not count toward the copayment/coinsurance maximum and will continue to be charged once it is reached."

"3 For non-emergency hospital services and supplies received from a non-preferred hospital, Blue Shield’s payment is limited to $250 per day. Members are responsible for all charges that
exceed $250 per day"
These clauses applies to:

OUTPATIENT SERVICES
– Non-Emergency services and procedures,
Outpatient surgery in hospital

HOSPITALIZATION SERVICES
– Inpatient semiprivate room and board, services
and supplies, and subacute care

OTHER
Delivery and all necessary inpatient
hospital services


The danger here, is that just because a hospital accepts an insurance company(blueshield), it does not mean that it is on the preferred hospital list. To get around this clause, you MUST have gone to a hospital for the surgery that was on the preferred hospital list. (they do this clause because a 'preferred' hospital has negotiated a smaller payment for the same services with the insurance company, and whatever the insurance company gives them is considered 'paid in full')

The only way you are going to have ground on appealing this, is if you actually had the procedure done at a preferred hospital.

Edited for additional info.

You should be able to do a search to see if your hospital is on their list here:
https://www.geoaccess.com/bsca/po/Qu...e=&FaPsearch=6

[mnflyfish]

Wow, $500 won't cover a paramedic ride to the hospital let alone anything else. I'd start by moving this into a writing campaign, then keep copies of everything yousend and receive. Good Luck,
Jay

[Spats]

The $500/day cap is for inpatient or outpatient procedures performed at an out-of-network hospital or surgical center. It sounds like they're claiming the place you went is out of network. You should be able to resolve that with a pointed letter.

*Always* document all contact with your insurance company: log all telephone conversations, keep copies of all written letters.

Keep in mind that this is how insurance companies make money. They deny claims for bogus reasons knowing that some percentage of people don't know how to fight them and their army of claims adjusters and lawyers.

[avacadotoast]

Huckasoreass, here's what I think is your summary of benefits

https://www.blueshieldca.com/bsc/fin...01-18-2000.pdf

BCBS has got to be adjudicating this as an out-of-network claim. If that's wrong and the facility you had the surgery is definitely in-netork than you something should be fixed.

For out-of-network non-emergency outpatient surgery they pay 50% and then any charges above their "allowable amount" on top of that AND your piece of this doesn't count toward your out-of-pocket max. Regardless if $2800 is their "allowed amount" for this then you'd be responsible for all but $1400...but again only if this is an out-of-network claim.

Definitely double check again and see if your doctor and the facility where you had your surgery are definitely In-network and go from there.

If your doctors office told you they were an in-network provider and that everything would be covered and they are not contracted that way, they have to eat it, period. It is their job to call BCBS and make sure of everything BEFORE they operate on you.

[haydukelives]

you are lucky to be in california for this one. you can file claims in small claims court for $5000., and you can break it up for separate charges. then look up the ceo home address if you can find it(not tooo hard these days on google) you can have the summons delivered by the sheriff for $25. EVEN AT THE OFFICE IT WORKS PRETTY WELL. If you can , be there with a camera and write a letter to your local paper.with a photo. i did this and got paid for the full amount in a few days. but i did have to promise not to sue them for damages.

[El Chupacabra]

*Always* document all contact with your insurance company: log all telephone conversations, keep copies of all written letters.

As someone who has to deal with insurance policy litigation nearly every damn day, this is advice that you must follow. If you aren't creating a solid paper trail to support your side, you will lose this fight.

If you want a referral to a California lawyer to help you out, send me a PM.

[huckasoreass]

I go through that Blue Shield preferred hospital locator page. My doc is listed. The hospital, Lake Tahoe Surgery Center, comes up on their list. The receptionist as the surgery center says they are a Blue Shield preferred provider. My doc did the surgery there and had me wait an extra month because the place is a Blue Shield preferred provider. Blue Shield tells me the place isn't on their list. What the... Can I start a conversation with my next Blue Shield operator tomorrow with, "Excuse me, I'd like to begin by asking you to get your head out of your ass and help me out?"

Thanks to everyone else who doesn't mind wasting so much time on this. You've been a help!

[shmoesmith]

sounds like they are on the list, and that you have a case...DOCUMENT, DOCUMENT, DOCUMENT. Make a copy of the webpage PROVING that the hospital and doc are on the preferred list. Document all phone calls.

Good luck, mang.

[teledave]

you are lucky to be in california for this one. you can file claims in small claims court for $5000., and you can break it up for separate charges. then look up the ceo home address if you can find it(not tooo hard these days on google) you can have the summons delivered by the sheriff for $25. EVEN AT THE OFFICE IT WORKS PRETTY WELL. If you can , be there with a camera and write a letter to your local paper.with a photo. i did this and got paid for the full amount in a few days. but i did have to promise not to sue them for damages.

That is funny as shit. Other than that, I'm not a lawyer but I have found the words "State Insurance Commissioner" strike fear in the hearts of insurance people for some reason. Good luck, Huck.

[PTracy P1]

damn dood. insurance hell.

[schuss]

sounds like they are on the list, and that you have a case...DOCUMENT, DOCUMENT, DOCUMENT. Make a copy of the webpage PROVING that the hospital and doc are on the preferred list. Document all phone calls.

Good luck, mang.

This is the truth right here. The good thing is that once they see some of that documentation, they should relent. I work for an insurance co., and practically every minute of my day in terms of work is filed away somewhere, likely for eternity.

[El Chupacabra]

I go through that Blue Shield preferred hospital locator page. My doc is listed. The hospital, Lake Tahoe Surgery Center, comes up on their list. The receptionist as the surgery center says they are a Blue Shield preferred provider. My doc did the surgery there and had me wait an extra month because the place is a Blue Shield preferred provider. Blue Shield tells me the place isn't on their list. What the... Can I start a conversation with my next Blue Shield operator tomorrow with, "Excuse me, I'd like to begin by asking you to get your head out of your ass and help me out?"

Thanks to everyone else who doesn't mind wasting so much time on this. You've been a help!

Print out that info from the website(s). Keep all this info in one central place (maintain a paper folder yourself).

[huckasoreass]

Print out that info from the website(s). Keep all this info in one central place (maintain a paper folder yourself).

Done. Everyone's advice, links, support have been awesome. I will update after a few calls.

[Que]

Bar none, BCBS of CA is the worse insurance company and policy that I've ever had. I personally loath those people (yes, those people, not just the company). The coverage is crap.... to tell you the truth, it was worse in several cases than actually having no coverage at all (the docs here give you a break when you pay in full in cash).

[LAN]

Sounds like you're well on your way, but here's a few hints from personal experience:

On our honeymoon I whacked my ankle surfing, and ended up having x-rays and treatment at a local doc-in-the-box. Since it was a clinic, the insurance company didn't look at it as "emergency" or "urgent" care. It took almost a year of phone calls between both the clinic itself and the insurance company to get things squared away - in the end, insurance covered everything except our emergency co-pay, once the care was recognized as such.

Can you call the surgery center and let them know that you're battling out the costs with your insurance company, and will withhold sending payment until you know the exact amount? Generally places like the clinic I went to and the surgery center are receptive to insurance issues and will cut you some slack when it comes time to pay.

Also, chances are the people you're talking with on the phone are just customer service agents. Ask for a manager or a specialist, and like everyone else said, document!

Good luck!

PS Were you able to find the clause that puts a cap on the 30% you're responsible for? Sometimes that type of thing isn't online, but rather in the manual that you get from the company itself.

[Chitown Pow]

where's Wapner...you're in Cali...if you tell your doctor he/she's not getting paid unless they figure it out..they will figure it out.

[shmoesmith]

any luck on this yet?