Insurance tactics

My name is Heather and i have BCBS of Alabama insurance i completed all my requirements in December and my surgeons office submitted the paperwork to BCBS on January 4, 2007, it too****il January 11th to show up in their system.  I  have called on a daily basis to check my status and until the 19th i was told every day that it was in review with the medical board and pending a decision. On January 19, 2007 when i called i was told that it was on hold waiting for my surgeons office to send my information ONLINE for predetermination. I explained that i was pretty certain my surgeons office did not do online submissions and that i was told on January 11th that all 27 pages of my information was received and has been in medical review since. She stated that because my surgeon was part of the online program that it would be the only way the insurance accepted the info.

I immediately contact my surgeons office and spoke with Stephanie the insurance coordinator who verified that they absolutely do not use the online service because of problems in the past getting BCBS to pay off the online approvals, she said that loooong ago they made the decision that BWI would not participate.

Took a few minutes to calm down and called BCBS back and asked to speak with a supervisor, i talked with the representative for over 10 minutes about the situation and she confirmed that the review commitee was waiting for this information from online submission. She did not have a supervisor available and said she would have the supervisor call me back after researching and that if the surgeon was part of the PMD network they must submit online.

Called back BCBS this morning since the supervisor never returned my call on Friday afternoon.  I was informed by this representative that my stuff was on hold until the provider representative worked things out with the surgeons office.  I asked what a "provider rep" was and he explained that it is the representative for BCBS that goes to the doctors offices to find out why they arent following the rules.  I asked if there was a number or any contact info for this rep to find out how long this process might take and he told me there was no way to contact them.  I said "how long will it take the rep to call my surgeons office?"  He advised they would go in person, not call and that it might take place "some time in the next week or so."  

I called Stephanie with the surgeons office and explained what they told me and she said this was one of their tactics to prolong the process and that they DO NOT and WILL NOT file online claims, she said they have steadily been getting approvals based on their faxed submissions and there has not been a problem.

Stephanie said she would call them today and get back with me.

I'm so discouraged at this point, its so frustrating to go through all these ridiculous requirements for so long and then be put on hold like this.  I hate that it's totally out of my hands also, i've done all i can do that i know of and now im forced to depend on others to act on my behalf.  Control freak much?  LOL

Has anyone had an experience like this?  Any suggestions?

Hi Heather: I also have BCBS of Alabama and had surgery in October '06.  I know for a fact that my surgeon's office did NOT submit my paperwork online, but rather by fax.  I did not have any of the problems you are referring to, but then again, my surgeon was out of network for BCBS.  Maybe that was the difference?  I got approved about 12 days after my information was received by BCBS from the surgeon.  I'm so sorry they are giving you the run-around...I honestly did expect it would happen to me, and was really surprised when it didn't.  I wonder if your surgeon's office could not just make an exception and go ahead and file online if BCBS is going to be that crazy about it.   I got a letter from BCBS when the surgery was approved and I would think the same would happen for you whether the info is submitted online or by fax.  They sent a letter out to both me and my surgeon's office.  Once you have the letter approving the surgery, that's all your surgeon should need to confirm that approval was granted and BCBS agreed to pay for the surgery.  I know they are hesitant to schedule surgery until they are assured of their money.   I will tell you however that BCBS just only paid my surgeon last week for my surgery in October of '06.  Can't say they are on the ball there.  I had to call them at least 5-6 times, bugging them to pay the surgeon.   I hope this all works out for you soon.  I know the waiting is torture, but I'm sure you will be approved in the end if you followed all their guidelines.  Good luck with your surgery!