Question:
The insurance has approved my surgery, but keep denying my claims?

I have Anthem Blue Cross Blue Shield Blue Prefered HMO. My surgery has already been approved. However, all of my procedures that I have had leading up to the surgery have been denied. This includes blood work, chest xray, upper GI scope, etc. I have called insurance and they said they will send it on to Medical Review. Has anybody else had this problem and did it resolve itself? Thanks!    — tammyelkins (posted on January 24, 2004)

January 24, 2004
I had a similar problem with my Blue Cross but it was for after the surgery. They wouldn't pay the anthesist. (Said it wasn't covered. Right.) Turned out the Anthesist used the wrong code when they filed. I would have your doctor's insurance person call the insurance.
   — jcooper

January 24, 2004
I had aetna. they also approved the surgery but did not pay a thing PRE OP..I have to pay out of pocket $5,000 but it is SSOOOOOOO worth it .Cheap price to save my life.
   — Kathy S.

January 24, 2004
I too have BC and some of my pre-op testing was not paid until after they paid my surgery bill. All I had to do was ask them to resubmit the bills and they were paid. Maybe this will work for you also. Good Luck!!
   — CAMFR

January 25, 2004
I had similiar issues with Anthem. They didn't pay anything until the pre-determnination was approved. They ended up paying for everything, except for about 50% of the pysch exam. They initially rejected all claims, but then I would call them and point them to the approved pre-determination. Once they saw that, they would resubmit and 30-45 days later they would pay. I've talked with several others that went through the same ordeal. Insurance would sure be cheaper if they just took the people overhead out of all these processes. My only advice is to be polite and persistent. You will find a CSR that will help. If not, call back in 30 minutes and see if you get another CSR.
   — rleffler

January 25, 2004
If your insurance company is sending your claims to medical review, chances are they are being looked at by an actual person, so chances are good that everything will be paid. Seems like a backwards way to do things, but I can see where someone might have all the testing and then decide to NOT have surgery, so then the insurance comapny would probably let the member pay the costs. That seems pretty reasonable since those costs for the testing would be paid by the premiums everyone else pays!
   — koogy

January 25, 2004
I had the same thing happen to me. I used to work for Aetna back in the day and when a claims processor gets your claim and sees the diagnosis code for obesity they automatically decline the claim as a non covered service. I had to call for all my claims make them look up the preapproval and send it back to be reprocessed. More often than not it is not covered, so the processor does not take the time to look to see if you are the rare one who had it preapproved. They have an amount of claims they have to get processed on a daily basis so if thye waste time looking at eachclaim that carefully they would not make their quota. Just a little insight :)
   — Melissa P.

January 25, 2004
I agree with the previous poster. Most plans don't cover treatment of obesity, except for surgery. And I find that with the larger insurance companies, one department doesn't know what the other is doing. One department approves, but for some reason doesn't have anything tied into the claims section to let them know it's approved. I work for a third party administrator who pays claims and we have sense enough to put a note in our system to flag these things. But with your carrier, just keep aggrevating them. Maybe your name will become so well known that the processor will know when he/she picks up your claim that it's to be covered. Good luck.
   — lharbison

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