It appears you have not yet Signed Up with our community. To Sign Up for free, please click here....



Health Insurance Issues Message Board
Post New Thread   Closed Thread
LinkBack Thread Tools
Old 12-02-2003, 06:34 PM   #16
Senior Member
 
Join Date: Aug 2003
Posts: 204
rubindj HB User
Re: Wanting some information!

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.

 
Old 12-04-2003, 05:13 PM   #17
Senior Veteran
 
Join Date: Oct 2003
Location: USA
Posts: 838
californiasunflower HB User
Re: Wanting some information!

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.

Last edited by californiasunflower; 12-04-2003 at 05:24 PM.

 
Sponsors Lightbulb
   
Old 12-04-2003, 05:22 PM   #18
Senior Veteran
 
Join Date: Oct 2003
Location: USA
Posts: 838
californiasunflower HB User
Re: Wanting some information!

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

Last edited by californiasunflower; 12-04-2003 at 05:23 PM.

 
Old 12-10-2003, 08:05 AM   #19
Senior Veteran
 
Join Date: Jul 2003
Location: Greenville, SC, USA
Posts: 578
Bothrops HB User
Re: Wanting some information!

Quote:
Originally Posted by mlwrn
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

 
Old 12-10-2003, 08:17 AM   #20
Senior Veteran
 
Join Date: Jul 2003
Location: Greenville, SC, USA
Posts: 578
Bothrops HB User
Re: Wanting some information!

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

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

 
Old 12-24-2003, 10:45 PM   #21
Senior Member
 
Join Date: Aug 2003
Posts: 204
rubindj HB User
Re: Wanting some information!

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.

 
Old 12-25-2003, 05:53 AM   #22
Junior Member
 
Join Date: Aug 2003
Posts: 24
krtylerwisconsin HB User
Re: Wanting some information!

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!

 
Old 01-06-2004, 09:34 AM   #23
Senior Veteran
 
Join Date: Oct 2003
Location: USA
Posts: 838
californiasunflower HB User
Re: Wanting some information!

Quote:
Originally Posted by rubindj
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!

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!

Last edited by californiasunflower; 01-06-2004 at 09:38 AM.

 
Old 02-24-2004, 05:35 PM   #24
Mara
Guest
 
Posts: n/a
Re: Wanting some information!

Have you resubmitted the claim?

 
Old 02-24-2004, 06:14 PM   #25
Member
(female)
 
Join Date: May 2003
Location: USA
Posts: 91
Gemi_Lee HB User
Re: Wanting some 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!

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

 
Old 02-25-2004, 03:53 PM   #26
Mara
Guest
 
Posts: n/a
Re: Wanting some information!

Quote:
Originally Posted by Gemi_Lee
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!

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 thatís 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! 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". 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... Take Care, Gemi

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

Last edited by Gemi; 02-25-2004 at 03:56 PM.

 
Old 02-29-2004, 10:38 AM   #27
Member
(female)
 
Join Date: May 2003
Location: USA
Posts: 91
Gemi_Lee HB User
Smile Re: Wanting some information!

Quote:
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 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!

Last edited by Gemi_Lee; 02-29-2004 at 10:39 AM.

 
Old 03-01-2004, 10:06 AM   #28
Mara
Guest
 
Posts: n/a
Re: Wanting some information!

Terrific, great news!

 
Closed Thread

Similar Threads
Thread Thread Starter Board Replies Last Post
I am new to the board, so wanting to say Hi.. rosebud49 Fibromyalgia 12 12-03-2008 11:29 PM
Wanting some insight about schizophrenia.. ckjk5 Schizophrenia 12 03-27-2006 04:29 PM
Wanting to Learn About MS Teacher_Lady Multiple Sclerosis 6 02-08-2005 10:49 PM
Ive been wanting to post, but had to get up the courage-ugh! hillaryb Relationship Health 86 11-26-2004 12:33 PM
Wanting information on Copaxone LoveKitten Multiple Sclerosis 2 08-11-2004 07:03 AM




Thread Tools

Posting Rules
You may not post new threads
You may not post replies
You may not post attachments
You may not edit your posts

BB code is On
Smilies are On
[IMG] code is Off
HTML code is Off
Trackbacks are Off
Pingbacks are Off
Refbacks are Off




Join Our Newsletter

Stay healthy through tips curated by our health experts.

Whoops,

There was a problem adding your email Try again

Thank You

Your email has been added











All times are GMT -7. The time now is 11:17 PM.



Site owned and operated by HealthBoards.comô
Terms of Use © 1998-2014 HealthBoards.comô All rights reserved.
Do not copy or redistribute in any form!