Question:
Ever been approved for surgery by ins. co and then have them deny?

I have BCBS thru my husband's employer ( Ford Motor Co.). So far everything is a go for this Tuesday (1-21-03). Iam going thru BTC in Ypsilanti Mich and I have been approved. I guess I was wondering if anyone who has BCBS of Mich who has had their surgery at the BTC ever had their surgery approved and then after their surgery have them turn around and deny? Just curious. I keep getting nightmares about having the surgery and then after the surgery getting a big bill in the mail for $30,000. Thanks!    — Kris T. (posted on January 18, 2003)

January 18, 2003
Please put your mind at rest. It is highly unlikely that your insurance has given you pre-approval and would then deny your claim. It's also unlikely that your surgeon's office would even deal with the insurance if that had happened in the past.
   — garw

January 18, 2003
As long as you got a written approval letter then put your mind at ease. I have had BCBS of WI for 14 years and they have never pulled anything like that. If it's approved in writing then it's approved. <p>However, just be aware of something called usual, customary and reasonable payment on charges. If BTC does not have a contract with BCBS then you might be responsible for all charges above UCR. Depending on what BTC and the others involved charge, it could be pretty significant but not anywhere near $30,000. Maybe like up to $3000. I know for sure my surgeon's fee is fully covered ($6000) and 99.9% chance the hospital charges will be fully covered based on past charges from this hospital and also a comment made to me by someone I work closely with at BCBS. I know the anesthesiologt won't be fully covered as their charge per unit is approx. $5 higher than what BCBS will allow. But the toal amount of units charges should not be more than 30 so that would be around $150. The rest of the charges should be fully covered. So I'd be looking at what ever co-pay I have left for the year, which will likely be none based on how this year has started, and the approx. $150 for the anesthesiologist. Not bad at all for something that will likely cost upwards of $40,000. Since self-pay is $26,000 I'm assuming it will run $10,000-15,000 higher than self-pay and that's without all the presurgery testing etc and my bi-pap machine and sleep study annd cat scan. It's been a banner year so far. <p>Most likely you are sitting in good shape unless you have some provider associated with this that is charging way out of line. If you notice a bunch of your anesthesiology bill not covered please contact me so I can explain how they are billed and paid. I have had 9 surgeries since 1994 and most of the surgery's anesthesiology bills came in not fully paid at first. Usually it's either the billing department of the provider or how it is entered into the insurance companies system. After digging into these bills and requesting reviews etc. I was able to get all fully paid except for 1 and that was one of the early ones before I understood how these bills are done. They are different than any other providers bills. It's not screwy once you understand but otherwise it's kind of strange. Relax and focus on recovery. Congratulations! I'm not far behind you -Feb 3rd. Chris
   — zoedogcbr

January 19, 2003
I just wanted to alert you to something I found out. My doctor and hospital were both in network, but the surgical assistant was not. I also had internists from a hospital group see me every day (and I had a LOT of hospital days. See my profile for details). Anyway, my brother called my insurance company and asked why they only paid out of network rates for those docs, since I had NO say in choosing them. They agreed and paid in-network rates for them. It helped quite a bit, as I have to pay 40% of out-of-network charges, plus the difference between what my insurance pays and what the docs charged. Also, most insurances have out-of-pocket maximums. Mine, for in-network is $5,000. I met that really early and then my insurance paid all of my in-network charges.
   — garw

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