Hi All
I had a heart attack last month! problem is my insurance blue cross/blue shield are refusing to pay for air transportation! Is their anything I can do to get them to pay for it? Any information would be appreciated.

Hi All
I had a heart attack last month! problem is my insurance blue cross/blue shield are refusing to pay for air transportation! Is their anything I can do to get them to pay for it? Any information would be appreciated.
Gemi Lee - I have a few questions for you and a place for you to start with your denial. Did they issue a denial letter? If so, what was the reason they denied this?
Also get a copy of your certificate of coverage. This will have listings of what is and isn't covered.
I know the answer to this question might be obvious, but was it medically necessary to be transported in this way or could you have been safely transported by a ambulance?
Also what type of plan do you have?

(I know these questions might seem a little strange but I worked in Grievance and Appeals for an Insurance Company for over three years and these are things that are looked at.)

I hope this helps to start.

Hi mlwrn Yes they did issue me a denial letter yesterday.
It said our review indicates this is not a covered benefit under my contract because documentation does not show medical necessity for air-ambulance transport,
The reason they air lift me was I had a heart attack I had a artery completely blocked they had to get me to a cardiac hospital where they could put a stent in my heart.........In the ER they gave me some blood clot busters they said their was a chance of me having a stroke before getting me to the other hospital so that was the reason they flew me out.
I am so mad at them..........you know what they charge for that? mine was almost $10,000.

I thought I had a great plan $500. deductable
co-pay-25.00
ER 20%
urgent care $50.
inpatient-20%
outpatient-20%
mental health-$25.00

Do you think I can check with the hospital to see if there report says it was medically neccesary for me to be air-lifted?

Thank you for responding

Gemmi Lee...Definitely get a complete copy of the medical records from the ER that treated you, the medical records from the air ambulance flight, and then the medical records from where you were transported to. These are all needed to paint a complete picture. Don't get discouraged, this is just the beginning and for the amount of money charged, it is definitely worth the fight.

Thanks mlwrn for your help! :)
I'll do that.

No Problem. Keep me posted on your progress and if you have any questions. I work in the Insurance Industry and kinda know some of the ins & outs. Don't be surprised if you have to pay for some of the medical records though. Also ask for itemized statements from all parties involved. This is another way to double check and make sure that you aren't being double billed or overcharged. Good Luck and hope you're feeling better now! :wave:

Ok, thanks again! :)

I'm still going round and round with the insurance company from last summer when there weren't surgical service available at the local hospital for my newborn and he had to be airlifted to a larger city. I'm being charged $750 extra, plus larger percentage in copays, for going out of network. Letters have been submitted to the insurance company by the doctor on call, director of medical services as per the insurance company's requirements and then they turn around and say that it STILL isn't enough.

I keep hearing from others that this is a common practice with insurance companies. That eventually they figure we'll give up and eat the costs. Meanwhile I've filed a complaint with the State Insurance Commissioner.

Ratatosk.. Several suggestions for you. 1. Have you obtained a copy of your certificate of coverage? This is the coverage document that specifically states what the Insurance covers and doesn't and in some detail. If you haven't, I would suggest you do so. 2. You might also want to contact the states Attorney General Office especially the Health Care Department. They along with the Dpeartment of Insurance, can possibly assist you in this matter. 3. Is this a PPO or an HMO? It can sometimes make a difference and there might be a few state laws to assist you. Check out these suggestions and I can continue to guide you from there. Definitely check out your state od residence website for possible assistance. Keep me posted and ask me any questions you would like possible answers to.

We have an HMO. Problem is that because it was a life and death situation -- the doctors had to move quickly and fly to a facility with surgical services for newborns. The one and only pediatric surgeon was on vacation, not expected back for a week. It was on the weekend -- and less than 12 hours later my son was in surgery. So we've got a larger percentage out of pocket, copay, deductible, etc for "going out of network". We HAVE contacted the state regarding this.

We started dealing with the insurance company verbally, asking what we needed to do to get permission for going out of network (after the fact). They told us we need a letter from the doctor on call. Which we had submitted and copied to us. Called a month later and was told that wasn't good enough -- they'd sent a letter to the doctor explaining that he needed to take a letter to the Director of Medical Service and they both needed to sign it and return it to the insurance company. The insurance company's response both times was "we got a letter from the doctor, but we didn't know what it was for" "we sent them a form telling them what to do and they haven't responded. Meanwhile the doctors are telling us they've submitted everything in writing they were told to do.

We've since mailed two packets of information -- bills, letters, statements of benefits -- requesting payment or to send us a letter explaining to us why coverage is denied -- show us in our policy Their response the first time -- we had to call them -- "you need to take a more proactive stance on your son's healthcare issues. We FINALLY did receive a letter denying or claims/asking for more information because there service terminated 10 years ago for the primary on the policy no coverage for my son. I took a second look at the documents -- we'd HAND DELIVERED the packets to the insurance headquarters -- they had FORWARDED on the request to another state where my spouse DID have coverage with that branch 10 years ago ???

We're to the point where they will be hearing from our attorney. We have filed complaints and they've fallen on deaf ears.

Hi there! :wave:

Blue Cross/Blue Shield will be reviewing the medical documentation for medical necessity but also will be looking to determine if the air lift was required due to the following:

1) Could the hospital you were originally transported to by ambulance able to treat your condition? If no, then they will look to see the next question.

2) The air lift took you to the nearest hospital available to treat your condition

Did the air ambulance company bill you for any waiting time? This is a non-benefit amount. After the insurance company reviews your claim and makes their payment, (key word here is "After") contact the air ambulance and negotiate them reducing the waiting fee amount. See if they will do an admin decision to waive it or reduce it.

Do not give up with appealing your claim. If you get no satisfaction from the carrier, write to your Congressman. Those are priority claims and the Plan has to respond to the Congressperson and to you within 30 days! Good Luck! Let us know what the outcome is! :bouncing:

Hi californiasunflower :wave:

1) Quote Could the hospital you were originally transported to by ambulance able to treat your condition? If no, then they will look to see the next question.

They were going to put a stent in like the next day there at this hospital......(this hospital is very small they don't do a lot of heart related emergencies right then)
they gave me all that medication that busts blood clots etc...but I was not doing very well.........I learned later that the main artery in my heart that was block the Dr.s called it the 'Widowmaker' very few people survive that artery when it's blocked I thank my lucky stars that I'm alive. :angel:

quote 2) The air lift took you to the nearest hospital available to treat your condition. Did the air ambulance company bill you for any waiting time?

No, the air ambulance didn't bill me for waiting time.......as soon as the Dr. told me I was being air lifted out they came & got me & off we went.

I've learned from another insurance salesman that their just being buttt holes about it their thinking that I will just go ahead & pay for the services he said to keep on appealing.......that's what I'm going to do til the very end.

Thanks for the information californiasunflower :)

Hi! I am so relieved that you were not billed for the waiting time!

Pardon me because I'm dealing with a vision problem but I re-read one of your posts with regards to why the air lift was necessary--because the hospital where your newborn was at did not have the surgical services available and the carrier is charging you more for going out of network. Another point I noticed that I want to bring to your attention. When you have NO CHOICE based on medical necessity reasons, EMERGENCY purposes and the subscriber is transported to the nearest out of network hospital (facility), the plan is suppose to reconsider the claim as if it were NETWORK hospital by paying the NETWORK Benefit Rate.

This too has to be brought up by the subscriber in writing (a reconsider letter) stating that "you had no choice" due to the emergency, etc. The Plan should review the claim involved (if I were the rep I would look at all claims involved--the whole picture--and reprocess them all at the subscriber's best interest--my point is that the Plan should do this at the "Reconsideration" level without you having to receive their denial letter offering appeal. They have the administrative decision power to do so. If they don't then please appeal. If this is FEP, OPM will admonish them and ask the Plan to reprocess the claim in accordance with the contract and the rules.

If this is not FEP, Provider Relations will have this knowledge and contract info too (if not, they will investigate if you write to them and call them) Provider Relation purposes goes beyond just keeping the network providers in line with waiving off the appropriate costs. They too will jump in and help get the subscriber's claims paid correctly. Without YOU there is NO Business. Contact them too. Get everyone on board to get this expedited. Trust me on this. If you need anymore help, please do not hesitate to post an SOS. You have two allies here on the board with experience that can help you. We'll be so happy to see your post that says you received your benefits! :D

Hope your newborn is doing well!

Thank you for your suggestions. Was having problems thinking of the wording for the next letter we'll be sending out. I've made copies of pages from my insurance benefit plan, which outlines the procedures for going out of network and it looks like we did everything we were supposed to do -- the provider just isn't responding -- as if we'll finally give up and go away. Not going to happen!

We had a similar run around with them last month. The doctor wrote a letter asking for preapproval for an expensive monthly vaccine to prevent/decrease the symptoms of RSV. Basically if my baby didn't get the shot and contracted the respiratory virus he WOULD be hospitalized for at least two weeks. The insurance company sat on the letter. When I called I was told that my child wasn't eligible. Had our attorney (relative) send a letter indicating that the doctor felt it was a medical necessity and within an HOUR he was approved.

If my child didn't receive the vaccine the costs of hospitalization for two weeks would be at least $70,000 compared to the cost of the shot per month for 5 months -- $800. Seems like a no brainer. To add insult to injury -- a rep from the insurance company sent us a nasty letter pretty much indicating that they didn't HAVE to approve the request -- just did it out of the "kindness of their hearts" but if for some reason there was something in our policy that didn't cover the shots --we'd be financially responsible for the full amount. The next week we get a letter from a different rep, copied to our doctor and attorney, saying that according to their policy, my child's condition makes him automatically approved for the vaccine.

Methinks I'm dealing with a couple individuals within the insurance company who are taking this all personally, acting as if the money is coming out of their own pockets. Very unprofessional in my opinion. Our attorney just shakes his head -- can't believe they would open themselves up to a potential lawsuit.

Hi There! :wave:

Sounds like you did a good job getting your reconsideration letter put together.
That always helps to include a copy of the benefit information from the booklet. FYI, the provider network book also may contain information too about out-of-network handling for situations that are beyond your control/emergency.

When the Plan receives a written inquiry or telephone call each have a timeline in which to respond. Of course, based on the load will depend on the response time too. I fret that Written emergencies may get lost in the shuffle.

Telephone inquiries have less days to respond back to the caller, and one would think the rep would hustle the emergency calls. Glad your personal attorney was able to get the ball rolling quicker. Save that letter that says the injection is payable! :p

I hope it all works out well!

As for the air ambulance services....

If everyone is a participant with BC/BS, then a denial for lack of medical neccessity is not your problem, its the air ambulance companies.

They can't collect the money from you, but have to write it off. If they start hassling you, call BC/BS, and they should take care of the problem as the air ambulance company will be in violation of their contract with BC/BS.

Rubindj--I regret that I have to disagree with your post about BC/BS providers having to write off charges for services denied based on no medical necessity.

Not Medically Necessary equals not a benefit (NAB) and is usually the subscriber's responsibility.

BC/BS Providers of service are only obligated to write off the balance between the allowed amount and the billed amount and other reasons such as "payment for this service was included with payment for another procedure performed on the same day--and the like. BC/BS Providers may charge the subscriber for copays, deductibles, and non-covered items.

If the benefit brochure clearly indicates that non-covered items (Exclusions)are service(s) deemed "not medically necessary", then those charges are the subscriber's responsibility unless supportive information is submitted to allow the Plan to update the claim to show otherwise.

GEMI-LEE, I hope you will please pardon me for being such a visual goof! Can you believe that those afflicted with very low vision are on the boards looking for answers and trying to help too! I just rrealized that I mixed up two different individual stories and I re-read every response I made to ensure that I gave proper info with regards to what I thought I read initially. I have who is who straight now! The info I gave out was correct with regards to BC/BS info and review process. I just wanted you to know that I hope YOUR review is going smoothly and that you'll let us know the results! Your story is incredible and I am so glad that you are here to post. How are you doing? It appears to me that there was medical necessity for the transport and once the Plan gets that documentation, the claims rep should be able to adjust it for payment. Let me know!

Your pal, CASunflower :angel:

Gemmi Lee...Definitely get a complete copy of the medical records from the ER that treated you, the medical records from the air ambulance flight, and then the medical records from where you were transported to. These are all needed to paint a complete picture. Don't get discouraged, this is just the beginning and for the amount of money charged, it is definitely worth the fight.

How can you not get discouraged? I have heard some pretty bad stuff regarding hospitalization and insurance, this has got to be the worst. It dosnt suprise me that the insurance co. dosnt want to pay. What shocks me is $15,000 for a helicoptor ride. A couple years back at an airshow I took a helicoptor ride for 15 min. at $25.00 a head. What I want to know is who sets the prices. I had a catscan done it cost $1100.00 and that was on an ancient machine. What part of that visit justified $1100.00. I dont have insurance. Only wealthy people have insurance in SC or those that work for huge companies.

As far as I am concerned anybody that is involved in this coruption can go straight to HELL and take all those that back them up with them. They can charge us whatever they want because our life depends on it. I could go on for hours about this. I would have to say this is the worst thing going on in our country and getting worse every day.

Derek

Im sorry $10,000 not $15,000. It still sucks!

How is it that all of you are so calm about these issues?

Sunflower---

I'm looked at a provider contract (at least in my state), and it explicitly states that not medically neccissary is the responsibility of the provider. On the other hand, a non-covered service is the responsibility of the patient (accupuncture, cosmetic, etc.). The only exception to this is if we have a signed statement from the patient saying that they want the service, realise it may not be covered, and agree to it anyway.

Hi there - I worked for BCBS in Customer Service, I have been on a medical leave, and am no longer employed as I could not return, so I'm not their representative anymore - I have no knowledge firsthand about your policy and your coverage would likely state all benefits are subject to benefits being available at the time of the incident or something.... But anyway, air ambulance is generally not covered. (To me, that always seemed illogical as people generally only take an air ambulance in situations they have no control over, never wanted, and certainly didn't requtest....).

Contact your Customer Service Dept, if you have not already done so, and ask them for the address to the Consumer Affairs Dept. That department is reponsible to review appeals. They review all types of case - by - case situations, and air ambulance is one. What you'll want to do is put your request for appeal in writing...giving as much detail about your situation as possible...they should then request medical documentation - if they don't already have it - to review the case to see if it was medically necessary for air transport.

If you get another denial, I would discuss with your physicians to verify it was necessary and if they agree, maybe try the dept of Insurance in your state. BCBS is required to follow up on those requests for information as well.

Good luck on your recovery!

Sunflower---

I'm looked at a provider contract (at least in my state), and it explicitly states that not medically neccissary is the responsibility of the provider. On the other hand, a non-covered service is the responsibility of the patient (accupuncture, cosmetic, etc.). The only exception to this is if we have a signed statement from the patient saying that they want the service, realise it may not be covered, and agree to it anyway.

Hi Rubindj! I regret the delay in responding. Been down with flare-ups. Hope that you had a happy holiday. Despite everything, holiday with family was good! :p

My hubby read your post to me and I've been thinking about how to respond. I don't have a copy of your benefit brochure and I am aware that with BCBS that benefits are based on contract benefits specifically listed in the benefit brochure. Usually the provider booklet will state that all benefits are subject to what is specifically listed in the benefit brochure (sorry to be so redundant). But I am aware that the Plans try to be consistent in all their publications.

With regards to emergency services and use of preferred and/or participating providers, there were times when subscribers did not have a CHOICE and were treated by non-participating providers. Therefore, if it truly was an emergency and there was no choice, the claim for services rendered at a facility and billed by an emergency room physician could be reconsidered at the maximum benefit rate (depending on the provider type, services rendered etc.).

In the benefit brochure, there is usually a list of exclusions. One for BCBS is typically no coverage for services that are not medically necessary.

I would have to see the text of your provider booklet and your benefit brochure list of exclusions to determine if a provider with BCBS would ever have to be responsible for a service that was not medically necessary. The logic is that medically necessary is not a benefit (NAB) and those items are always the subscriber's responsibility. A provider with BCBS agrees to accept the allowed amounts as payment in full and only to charge the covered patients for deductibles, non-covered services and copays.

With regards to air ambulance, if your benefit brochure lists it as a covered provider then the services should be covered if medically necessary. Again, the Plan would need documentation to support the transport from facility to facility. It should be covered it the facility could not treat the patient and the patient was transported to the nearest facility that could render the necessary medical care. Reconsiderations should be done in writing as well as appeals and if necessary, get Consumer Affairs, Dept. of Corporations, and your local Congressperson on the case. Consumer Affairs should be a good first try. The Plan's MAIN office should have a dept. If your appeal gets upheld by the Plan, you then have a right to pursue the matter judicially. A court judge will certainly understand the medical necessity and may order the Plan to pay. Have the supporting documentation including your Plan's response to your appeal upholding their decision if you go that route. Good luck!

Have you resubmitted the claim?

Hey There
Yep, I've resubmitted the claim & I recieved another denial letter! The letter says....

He advises that the run sheet indicates that you were not transported until more than 8 hours past the onset of pain. He continues that catheterization with stenting in the first 6 hours past the onset can salvage the myocardium. However, after 6 hours, an additional 40 minutes to transport by ground ambulance would not statistically affect the clinical course! :mad:

Is this the next step I need to take Consumer Affairs?
get Consumer Affairs, Dept. of Corporations, and your local Congressperson on the case. Consumer Affairs should be a good!

I'm getting really aggravated with this whole stituation!
Thanks everyone for the information.

Hey There
Yep, I've resubmitted the claim & I recieved another denial letter! The letter says....

He advises that the run sheet indicates that you were not transported until more than 8 hours past the onset of pain. He continues that catheterization with stenting in the first 6 hours past the onset can salvage the myocardium. However, after 6 hours, an additional 40 minutes to transport by ground ambulance would not statistically affect the clinical course! :mad:

Is this the next step I need to take Consumer Affairs?

I'm getting really aggravated with this whole stituation!
Thanks everyone for the information.

Hi Gemi Lee, hang in there. (I was gonna say General Lee :)
It sounds like they are questioning the basis of treatment, protocol & cardiac classification. Issues...was it AMI or ischemic? The doctor (thank G-d its him and not you) has to provide basis, necessity & prove treatment protocol. How was the pain event determined and what did they base it on? They may be looking for more information to substantiate, so back in the doctors hands it goes. If I were you I would keep resubmitting until they pay it.

It sounds like a tennis, boxing match between the insurance company and the doctor. Keep resubmitting the forms until the insurance company has enough verifiable information from the doctor to satisfy, then finally pay the claim. The insurance company will question chunky disbursements, ask questions first and the provider is explaining his actions. At this point it would seem it is back in the doctors hands to justify this "time response" issue they raise. I'd keep resubmitting and make sure you get copies of what is submitted & the response from both sides until it's resolved. I'd imagine the finding of LAD-The Widowmaker would factor in...Is the clinical course of transient myocardial pain revealing in high risk, LAD AMI cases, subacute or silent? Are the majority of MI cases asymptomatic? Were serum markers & wave changes considered? Is the goal of treatment to restore flow and reduce risk of further complications? Bottom line, the doctor will need to prove medical necessity to the ins. people to their doctors satisfaction (yeah I know, the whole thing stinks) then they will pay it...It was horrible enough you almost lost your life then these people send a shocking bill?!?

I feel for you. Insurance issues are aggravating. There are times I've had to fight and follow up to get medical bills paid, properly coded and what have you, it's terrible. You would think, you do your thing, what your supposed to, think your covered and they pull this out of the hat. It's something else...your on the darn gurney & are still supposed to have presence of mind to question all (sigh) Do I sign the discharge papers so the other place can help me because that’s what the doctors telling me I have to do? It does not exactly instill confidence to get a bill like this but it will work out in the end, it will take time.

I recently received a bill for the professional component that was done over a year ago and this was the first notice I received! :eek: I made the gazillion calls to find out who this provider was (not recognized, it ended up being the professional component to the biopsy I had done at a hospital, meanwhile this was not billed through the hospital and was billed privately-ah ha!!!). Everything else was paid for but this. I made more calls and thank G-d for the billing experience I have, I knew to sink my heels in & handle it in that regard. The insurance company said one thing and this providers billing dept. said another. Caught them both in there "tag" game of "not it". :nono: What was worse was it was through med. insurance I no longer had. How was I gonna get them to pay this now, so long after the fact? I realized they had their end of quarter coming up and suggested if they could not collect to put it through as a loss because I flat out refused to pay for something that should have been covered & that it's not my problem they don't code or submit the billing within time limits or properly (blah-blah and blah). The insurance company tried to get out of it by claiming it was "out of network" which was untrue (nice try-that loophole) You would think if the hospital is participating the services you receive there are covered but that's not always so, a rude awakening.
The providers office called me back and told me it was going to be paid and the insurance company even sent me a letter confirming the same. It did not happen without aggravation. Hope this encourages you not to give up. :)
It will work out. It will... :wave: Take Care, Gemi

Ps: Let them battle it out. You don't need the added stress of this on top of what you’re already dealing with. Hope you are feeling better :) :angel:

He advises that the run sheet indicates that you were not transported until more than 8 hours past the onset of pain. He continues that catheterization with stenting in the first 6 hours past the onset can salvage the myocardium. However, after 6 hours, an additional 40 minutes to transport by ground ambulance would not statistically affect the clinical course

I just wanted to let everyone know after submitted more documents concerning 'the run sheet' a few weeks ago it finally paid off!
To all of you that help me with information regarding my denial claim......
Blue Cross/Blue Shield is going to pay for my air transportation $9,175.00 this is such great news :bouncing: no more submitting this, trying to find that, I had tears of joy in my eyes believe it or not! ;) they probably won't pay all of it but this will be a big help with all my other medical bills.
Thanks everyone! :)

Terrific, great news! :)