Hi all,
Those of you who know me, know my history of trying to find a “true” diagnosis for pelvic pain (plus I have MRI’s showing 2 hern, disc.) Anyway, I went from Pennsylvania to Arizona to go to the Mayo Clinic (and back out to AZ to live). Now, this hospital had my health insurance information 4 months before my initial appointment. I went through all of my appointments asking the receptionist what I owed and they always said nothing, your covered by Blue Cross. Keep in mind the Mayo not only sent me from doctor to doctor, but ordered testing all over again. For example another MRI, Ultrasound, EMG and blood work. Well, today I received a letter from the Mayo claiming I owe them a phenomenal amount of money because they are considered out of network!!! I also checked with blue cross before I went to the Mayo and they said I was covered “everywhere” They had my insurance info back in June and my first appointment was Sept. I finished with the Mayo in Dec. To come back to Pa and they are just now getting around to telling me this. Does this sound right? Any suggestions on how to fight this???? We are talking thousands of dollars!!!!

Insurance companies are a pain in the butt. They play alot of games to save money. Did you by any chance take notes on who you spoke to and when? One thing I learned is that you should always take notes, don't trust the doctors or the insurance to cover your butt. Make sure in the future you do.

I have a very extensive, expensive problem, TMJ. I always take notes on who I talk to, their extension if possible, date, time and subject. The insurance company is supposed to keep a log on the same. Maybe you can call a few times until you find a caring soul, willing to look through the screen notes and read them back to you. If not maybe a local doctor helped you set things up and has notes. I am on an HMO so I have to have my primary physican write all referrals. POS plans work the same.

After you get all the information you can, appeal through your insurance company. They have a form you need to request. You must file an appeal within so many days I think. They then have 30? days to respond.Try the above BEFORE you request an appeal form, as certainly they will tighten up knowing a fight is coming.

Unfortunately, I too learned the above the hard way. I had a daughter in August of 1997 in Florida. Months before labor I requested a tubal (to prevent further pregnancies). My insurance company issued the approval numbers. In September of 1997, one month AFTER the surgery, I got a letter saying the authorization was being withdrawn and it was not a covered benefit. I contacted my doctor and he had all the authorization numbers. I appealed and they still refused to pay. Not only did they not pay the tubal, they would not pay the labor bill until it was all cleared up. I called around and found the department of insurance for Florida. I filed a complaint with them against the insurance company. It took three years, but since I kept the hospital informed, I was not sent to collections. Finally in 2000 the claim was paid. Just don't give up the fight. Eventually they may give in. If you don't get anywhere call your states Department of Insurance, every state has one. They can direct you on what to do. You may even be able to research and file a complaint online.

To protect your credit in the mean time, you may want to set up a minor payment arrangement, like $25 a week or month. I believe as long as you make timely payments, they cannot send you to collections (but double check this, some states are different) and keep in mind you are dealing with services from another state so that is where you need to check.

If you have an individual health plan, I would look into changing at your next renewal as your rates will probably skyrocket. If you have a group health plan you should be alright because they have to take everyone as a bundle package.

Hope this helps. I know it is frustrating but stick with it. Since I know the trouble i've had, i've gotten into the habit of calling the insurance direct before any test or surgery to get the precert numbers directly and cover my butt. It stinks we have to do this but in the end it gets the bill paid.

Good luck!

Pippin31,
Sorry to hear about your experience, working in the Ins industry, and w/in the Blue Cross Blue Shield Assoc, I can tell you it shouldn't be hard to get this turned around, or part of it at least. Have you looked at your Patient Bill of Rights? Do that if you haven't! First keep in mind that when you call customer svc at your ins they will be willing to help but happy to help if you don't yell. It is policy that if there is a benefit misquote they have to cover it. (A guy in CS onetime said we would pay for implants and we had to b/c he noted it so the patient was telling the truth) First ask if you have out of state benefits. Mayo clinic is not contracted w/ your BC of PA but it is w/ AZ and that is the provider contract that they should be going by. It's part of the benefit of having the Bluecard program. I would make sure that the clms went through Bluecard (they may call it OAP or Nationals dept.) When the provider is contracted they have to take an adjustment to the services that the local BC of AZ has assigned to the CPT (procedure) codes that were submitted. Any Out of Contract request that you do should be out of PA but if this is a plan that you are purchasing yourself than you should be purshasing a plan out of AZ if you have moved there, other wise you will run in to continually reduced benefits. But then the Customer Svc dept of your ins should have notified you of that if they know. Hope this helps in some way, and it may be redundant from what the other said but I didn't read it all and there is info that is more specific to your case. Blue Cross never will revoke a Prior-authorization, that is illegal if you have already received the services, in Washington at least. Hope all goes well.