Calling Diana Cox

southernlady5464
on 3/14/11 7:20 pm
DS on 01/24/11 with
Okay need insurance help. I had a pre-auth for my surgery, covered at 100%. I have a Medicare Advantage policy thru BCBSTN. Just got notice they denied it and expect me to pay it, both the hopsital bill and the surgeon's bill.

The pre-auth was good for more than a week past the date of my actual surgery so I know it was good. Also my coverage was based on Medicare's coverage at 100%.

I was beginning to worry when it was taking over a month in processing.

Help, please.

Any ideas?

Liz

Duodenal Switch (Lap) 01-24-11 | Surgeon: Stephen Boyce | High weight: 250 in 2002 | Surgery weight: 203 | Lowest weight: 121 | Current weight: 140 | Goal weight: 135

PM here to get into R&R 3








   

Ms. Cal Culator
on 3/14/11 7:41 pm, edited 3/14/11 10:15 pm - Tuvalu


I'm not Diana and I have no clue what she'd want to know...but I'd like to know if you have a copy of the written pre-auth.



I ask because I did, and then they turned me down AFTER THE FACT and then I found the phone number for their legal office and asked them if they REALLY wanted to play that game and they fixed it by the next day.  (I did NOT go through the appeal process on this one because it was just a bull**** way to keep me busy and I was too sick post-op.  Well, not too sick to intimidate someone in their legal office, but too sick to deal with a month of CSRs who had no power to do anything anyway.)
southernlady5464
on 3/14/11 7:47 pm
DS on 01/24/11 with
YES, MA'AM, I do...I have it tucked away safely because I had a bad feeling this might happen when I saw processing beside it for so long.

In the meantime, I've been looking up the state insurance commission (not as easy as it sounds for this state) cause I know that is another place to go.

I didn't start crying but damn..staring at a 50K bill will scare anyone out of their wits! Liz

Duodenal Switch (Lap) 01-24-11 | Surgeon: Stephen Boyce | High weight: 250 in 2002 | Surgery weight: 203 | Lowest weight: 121 | Current weight: 140 | Goal weight: 135

PM here to get into R&R 3








   

(deactivated member)
on 3/14/11 8:00 pm - San Jose, CA

For the record:

I AM NOT AN INSURANCE LAWYER; I AM NOT LICENSED TO PRACTICE IN TN; THIS IS NOT LEGAL ADVICE.

Why did they deny?  I can't answer ANYTHING without knowing what they said.

But in the meantime, do what Sue told you to do.

In CA, appeals regarding Medicare coverage, even if administered by a "real" insurance company, do not go through the state Dept. of Insurance.  The route of appeal should be on your paperwork.  And undoubtedly (unless Sue's suggestion works), you have to first exhaust your internal appeals with BCBSTN.
 

southernlady5464
on 3/14/11 8:17 pm
DS on 01/24/11 with
I know you are not an insurance lawyer or licensed to practice in TN,  but you do have good ideas. And sometimes that's all we need. :)

Right now, I do not know as I have not recieved a denial letter. Usually all I recieve is a notice of the EOB and that is it. To that part, I plan on calling as soon as they open in the morning to ask if I will recieve a denial letter.

Then I will do as Sue told me to do...I am currently trying to find the legal deptartment's phone number. I know they have to have one but they seem to have buried it so well, it has been hard to find. Haven't given up yet, but google hasn't located it yet.

I did go to the cms.gov site (that is the site that oversee's medicare coverage outside of medicare.gov). They coordinate coverage between medicare and medicare advantage.

Any other ideas, let me know, please.

Duodenal Switch (Lap) 01-24-11 | Surgeon: Stephen Boyce | High weight: 250 in 2002 | Surgery weight: 203 | Lowest weight: 121 | Current weight: 140 | Goal weight: 135

PM here to get into R&R 3








   

(deactivated member)
on 3/14/11 8:55 pm - San Jose, CA
I just put that disclaimer in every once in a while to make sure people know what kind of help I can give.

One thing to check, since your surgeon is not one of the "regulars," is whether he coded your surgery correctly when they submitted for payment.  CPT 43845 is what Medicare covers.  Not some other way to code it.
southernlady5464
on 3/14/11 9:19 pm
DS on 01/24/11 with
One would HOPE he coded it correctly, LOL...but that is a good one to check. Thanks.

Liz

Duodenal Switch (Lap) 01-24-11 | Surgeon: Stephen Boyce | High weight: 250 in 2002 | Surgery weight: 203 | Lowest weight: 121 | Current weight: 140 | Goal weight: 135

PM here to get into R&R 3








   

Ms. Cal Culator
on 3/15/11 7:15 am - Tuvalu
On March 14, 2011 at 8:17 PM Pacific Time, southernlady5464 wrote:
I know you are not an insurance lawyer or licensed to practice in TN,  but you do have good ideas. And sometimes that's all we need. :)

Right now, I do not know as I have not recieved a denial letter. Usually all I recieve is a notice of the EOB and that is it. To that part, I plan on calling as soon as they open in the morning to ask if I will recieve a denial letter.

Then I will do as Sue told me to do...I am currently trying to find the legal deptartment's phone number. I know they have to have one but they seem to have buried it so well, it has been hard to find. Haven't given up yet, but google hasn't located it yet.

I did go to the cms.gov site (that is the site that oversee's medicare coverage outside of medicare.gov). They coordinate coverage between medicare and medicare advantage.

Any other ideas, let me know, please.


probably went to Yahoo finance and looked at the names of the high rollers and found the name of someone who was a high roller in the legal department and then probably went to a press release and found a phone number of a live person and then somehow got transfered to the general vicinity of the high roller, but close enough that I was in the right department.  (It's been over five years and I was loaded at the time...lol...but that strikes me as one way I would approach that issue.)
southernlady5464
on 3/15/11 10:08 am
DS on 01/24/11 with
Update on this issue:

This morning, I started with the billing deptartments of both the surgeon's office and the hospital. Something someone said on the DS facebook group also made sense. They want to get paid as badly as I do NOT want to pay. So I called them. They had not seen the EOB's yet...still too soon as I just got them yesterday.

They did tell me they WILL deal with them as soon as they see them and refile. That having them denied is not at all unusual. They did have my pre-authorization on file and for me not to worry yet. It would probably take a month for them to get anything at all so to just sit back for now and hold on to all my paperwork.

The clerk at the hospital even said that 99.99% of them end up being paid the second time, she didn't know why the insurance companies do this,  it just causes extra paperwork.

So for now, I am on hold. I will let them do their work first.

Liz


Duodenal Switch (Lap) 01-24-11 | Surgeon: Stephen Boyce | High weight: 250 in 2002 | Surgery weight: 203 | Lowest weight: 121 | Current weight: 140 | Goal weight: 135

PM here to get into R&R 3








   

(deactivated member)
on 3/14/11 9:36 pm - TX
Just being nosey here, since my friend is trying to get things covered thru Medicare and has been denied several times.  The underwriter in TX (Trailblazer) has put exemptions in their policy that exclude her from WLS because she was diagnosed bipolar, and that is why she is on disability, and why she has Medicare.  So she has a no go there.

Do you know who the underwriter is in your state?
southernlady5464
on 3/15/11 6:24 am
DS on 01/24/11 with
Is your friend on Medicare or Medicare Advantage? There is a difference. On Medicare, there isn't an issue...she is covered for WLS. And actually on Medicare Advantage, there SHOULD be a clause in the policy that says "except when considered MEDICALLY necessary".

Liz

Duodenal Switch (Lap) 01-24-11 | Surgeon: Stephen Boyce | High weight: 250 in 2002 | Surgery weight: 203 | Lowest weight: 121 | Current weight: 140 | Goal weight: 135

PM here to get into R&R 3








   

Janine P.
on 3/15/11 6:00 am - Long Island, NY
DS on 05/03/11 with
I love these...
 
WWDCD's?

 

Janine   Me on Youtube 

 

(deactivated member)
on 3/15/11 7:40 am - San Jose, CA
Oh HELL to the NO (I'm not sure what that means, but it seems emphatic enough)!!!

In any case, it is easier for me to SAy than to DO.
keliblue
on 3/15/11 2:21 pm - Georgetown, CA
I also was approved and then got a bill for $168,000.00   talk abou****ching the blood drain from your face..you start questiong yourself..  Ohhhhh **** where did I put that approval letter !!    called my issurance company.. oopsie... sorry about that.. disregard that letter.. our mistake

 Idiots !!

FAITH..TRUST & PIXIE DUST.....

        
southernlady5464
on 3/15/11 2:35 pm
DS on 01/24/11 with
Yeah, I can see that happening. I would have probably fainted.

But I had watched the claims sit there for a month "processing" so I knew something was up. This isn't a "opps, I'm sorry on their part" They meant to do it. Now to get the surgeon's office and the hospital battling for their money. They are use to it and they want their money worse than I want them paid, LOL.

Duodenal Switch (Lap) 01-24-11 | Surgeon: Stephen Boyce | High weight: 250 in 2002 | Surgery weight: 203 | Lowest weight: 121 | Current weight: 140 | Goal weight: 135

PM here to get into R&R 3








   

NoMore B.
on 12/17/11 7:15 pm
 Bump