Musings of a Medical Zebra

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Posts Tagged ‘ehlers-danlos-syndrome’

Blue Cross “found” The Pre-Approval Number

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July 11th, 2015 Posted 3:15 pm

The kind people who deal with collections at the office where I had my PET Scan offered to submit an appeal for me. In the process of getting the appeal information together, one of these kind people called Blue Cross again. The woman called me later the same day to tell me the good news: Blue Cross was processing my claim. This was such a relief, and particularly great news given that it came a couple days before Christmas.

If you read my previous post, you’ll recall that my doctor’s nurse obtained a pre-approval number for my PET scan. Blue Cross should have processed the claim, but they told us that a pre-approval was never submitted. The Blue Cross representative, interestingly, asked my husband if we had the pre-approval in writing. Though they told him that they always send pre-approval letters to patients as they are processed, I have yet to receive one. I’ve had multiple MRIs and CT scans, but I have never received a copy of the pre-approval from Blue Cross.

During my phone conversation with the woman from collections, she told me that she had to pressure the Blue Cross representative for some time. Eventually, the Blue Cross representative admitted that they DID process the pre-approval for my PET scan. They had simply “misplaced” the documents involved with the pre-approval. I also learned during the phone conversation that Blue Cross regularly claims that they didn’t process pre-approvals for expensive tests like PET scans. (The bill for my PET scan was over $4,000.)

I’m confident that Blue Cross didn’t “misplace” anything related to my pre-approval. I’m confident that Blue Cross LIED. Blue Cross LIED to us on the phone when they told us they had no evidence of my pre-approval. Blue Cross LIED to my doctor’s nurse – – the same nurse who, God bless her, obtained the pre-approval and recorded the pre-approval number – – when she called on my behalf. Blue Cross LIED to the woman from the collections office during multiple phone conversations. I’m confident that Blue Cross is LYING to other patients about their pre-approvals right now.

If you have had a pre-approved claim denied by your insurance company, don’t be discouraged. Get the pre-approval number from the doctor’s office who ordered the test. When you receive the Explanation of Benefits (EOB) from your insurance company indicating the claim’s denial, call your insurance company and provide the pre-approval number. Ask for the name of person you spoke with – – always get the name of the people you speak with on the phone – – and write it down. Document the date and time, along with the conversation itself. If the insurance company still refuses to process the claim, call the office where the test was preformed. Provide them with the pre-approval number, and ask if they would be willing to contact the insurance company on your behalf. If you have to submit an appeal, ask the office if they can assist you with it or submit it for you. If you have to submit the appeal yourself, call your insurance company to find out what they require in the appeal and when the appeal has to be submitted. If you have anything to add to this, please leave a comment. 🙂

Blue Cross Denied My Pre-approved PET Scan!

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December 22nd, 2014 Posted 12:38 pm

Last week I received an Explanation of Benefits (EOB) for my PET scan. I was quite surprised to find that my insurance – – by “my” insurance I mean the insurance my husband and I have through his employer – – denied the claim, making us responsible for the entire $4,100 bill. According to the insurance, Blue Cross, the test was medically unnecessary.

I began making phone calls in an attempt to sort out the mess. My doctor’s nurse seemed like the place to start, since she told me that she’d be taking care of the pre-approval. However, when I spoke with her on the phone, I learned that she doesn’t take care of the pre-approvals directly — rather, my doctor’s office contracts with a company that does it for them. I also learned that the test was pre-approved and that the nurse was given a confirmation number corresponding to the pre-approval. She gave me the confirmation number, along with the name of the company that was responsible for the pre-approval.

Meanwhile, my husband called Blue Cross and was told by a representative that they didn’t receive a request for pre-approval. (Isn’t that convenient?!) She asked if we had anything in writing that shows the PET scan was approved. (Nice!) My husband told her we have a confirmation number from the company that got the pre-approval. Of course the confirmation number meant nothing to her. (Again, convenient!)

I called the office that is handling the billing. The woman on the other end was interested in the confirmation number, so I gave it to her. She told me she would research the issue and call me back within a week. A couple hours later, my phone rang. It was the billing office. I was told that they were going to file an appeal. She said it would take 4-6 weeks to get a decision. I’ll hear back from them at that time.

I plan to call the company that handled the pre-approval. I am hoping that if I give them the confirmation number that they’ll be able to provide me with proof — perhaps a letter from Blue Cross — of the pre-approval. Providing evidence that the test was pre-approved should make the appeal unnecessary. That’s what a reasonable person would think. Unfortunately, insurance companies can be anything but reasonable.

I plan to make a couple phone calls this afternoon. I’ll update this when I have new information to share.