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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.