Blue Cross Blue Shield refuses to pay my little brothers $30,000 hospital bill

[RyanPsych]

due to his appendicitis- removal and medicine.

My parents pay well over $15,000 a year in premiums.

This is beyond ridiculous. What the hell is wrong with this country

[virgogal]

1. Why? What reason did they give?

[The Velveteen Ocelot]

2. Why did they deny the claim?

[RyanPsych]

4. Their health care "expert"

claims that is was an unnecessary expense

[ChazII]

6. Sorry to be dense but who was the 'expert'?

My best friend's son, j had similar surgery last month and also has Blue Cross.

[RyanPsych]

10. I wish

that I knew for sure. Best I can tell- it is someone with medical knowledge that makes calls on whether a procedure was absolutely necessary or not. Basically- a tool.

[Horse with no Name]

21. I had gynecological surgery

the "expert" they called on was an old retired general surgeon who didn't have first hand knowledge of the procedure I had done. I contested the "expert" and BCBS ended up having to schedule a conference call between my doctor (an OB-GYN who has national recognition and certifications). He shut him down and they approved the surgery after 2 years. For all you know, their medical expert was a psychiatrist. That would be where I started the argument--calling their expert into question.

[haele]

15. Appendicitis kills. It wasn't a necessary expense to remove it?

Some health expert. Probably thought it was the same sort of procedure as getting tonsils removed -
Oh, wait, if the post-lingual tonsils get inflamed and swollen, they can close up your windpipe right above the larynx.

Haele

[kestrel91316]

23. No. The kid had a duty to die.

[Horse with no Name]

19. Easy enough to prove

the pathology report should prove the appendicitis.

I am wondering if he stayed longer than 24 hours though--because they won't cover that unless it was perforated...but even then the MD can write a letter of medical necessity.

I also have to wonder if perhaps there wasn't a pre-authorization done? That is usually how they snake out of paying...and there generally isn't any getting around that one, however, the hospital usually has a person who does these things.

Good luck getting it worked out. Last time I had to fight it, it took almost 2 years to get them to pay it--and I did so by challenging their medical expert.

[RyanPsych]

24. Stayed less than 24 hours, actually

and my mom said that if she had know that they would snake out it than she would have just taken him home after it was removed (she was a nurse before she decided to be an engineer...woman is an over achiever)

[Horse with no Name]

27. that is medically appropriate. I'd challenge the expert. n/t

[AmBlue]

49. BCBS did that to me and I won.

I'm in Florida and they denied me coverage for a surgery that I needed and claimed it fell under the pre-existing condition clause. I proved it was not a pre-existing condition and they kept giving me the run around. So I reported them to the consumer protection division of our State CFO's office, at the time Alex Sink was our CFO. I was assigned a caseworker right away and she gave me her direct line and said it would take 3 weeks for them to investigate. In exactly 3 weeks, I was notified that BCBS had reevaluated my case and would accept my claim. I had my surgery and they paid.

So, whatever state you're in, find out what state agency you should report them to. The report you make becomes public record. I'd be willing to bet that with a little heat they'll change their tune.

[BlueIris]

52. Thanks for sharing that. It gives me (a bit of) hope. nt

[AmBlue]

53. You're welcome & good luck!

They hate publicity and oversight... So any way you can apply pressure from those two directions, you've got a better chance.

[anneboleyn]

54. Please consider challenging this -- ask the brother's doctor and/or the admitting physician to help.

They should be able to write up a report or otherwise contact the insurance company to challenge this preposterous claim. (ask the surgeon as well)

[ixion]

3. what's wrong? The Health 'care' industry, for starters, but it's a long, long list

but yeah, Big Med has gamed the field to a point beyond ludicrous.

[eridani]

5. ACA makes claims denial perfectly legal

Sure you can appeal, if you want to spend most of your non-work hours doing it. In all countries with universal health care mediated by private insurance, claims denial is flat out ILLEGAL. No deductibles or age rating either.

[RyanPsych]

11. They've appealed

and sent paperwork and all the hoops and what not.

My mom was describing all the confusing and redundant machines she had to talk to on the phone- and yet she still has no idea what to do.

So far as it seems- they seem to be ignoring it all together.

[uberblonde]

18. Report it to your state insurance commission.

I guarantee you, they'll be a lot more agreeable.

[Horse with no Name]

22. Depends on the state

I appealed mine to the state in Texas and they said there was nothing they could do about it.

[RyanPsych]

26. They live in Texas

...fucking great

[NotThisTime]

48. I have so much experience with this... start keeping records, get the doctors office involved to

challenge their so called expert. Have it re-processed after the doctor talks to them.. if it is denied, then go through your first formal appeal.... meanwhile start calling the State's agency that deals with insurance, tell BCBS you are in contact with them... they can lose their right to provide insurance, you can make a complaint with that agency. Document everything... if the first formal appeal is denied, you still have the bite at the second apple, if it's denied after that, there are no more appeals. So make sure you have documentation from the doctor specifically... If this plan is administered through an HR department, get them involved... get them involved today....

I can't tell you how much I've had denied and how much time I have spent getting it paid...

[enough]

7. How often and how long can this sort of thing keep happening before there is

an awakening among the people of our country?

Beyond ridiculous indeed. It sounds like criminal fraud to me. They say they are selling medical insurance, but apparently they are not.

Best to you and your family in dealing with this.

[eridani]

16. For quite a long time, unfortunately, because most people will never get expensively sick

In every age demographic, 5% of that demographic accounts for 50% of all health care expenditures. 15% of the demographic accounts for 85% of expenses. There is no personal interest to motivate the 85% who spend only 15% of health care dollars to give a shit, other than moral and ethical concern about others. That seems to be in short supply these days.

[RyanPsych]

28. they are selling a con job

plain and simple

[Mariana]

43. They won't wake up because they just don't see it.

They'll continue to believe that the US has the very best system in the world, and all those countries with single payer systems are just killing people off wholesale. That's what they're told and that's what they believe.

Shit, they'll believe it even when they're victims of this system!

My mom's had various claims denied time after time. She's very good at appealing them and getting stuff paid for after all, but the stress of doing that over and over again has taken its own toll. She has what are pretty close to panic attacks whenever an envelope arrives in the mail from BCBS, before she even opens it, and her blood pressure skyrockets. This is bad news for a woman who's already had a FUCKING STROKE! And, one of the claims they routinely deny is the (expensive) brand name blood pressure med she has to take because she's SEVERELY ALLERGIC to some ingredient in the generic they want her to take. She has to fight that every single time the scrip is refilled!

(BTW, she recovered almost entirely from the stroke and her only permanent loss of function from it was some peripheral vision on one side.)

She still believes she'd have been written off and dead long since if she lived in a country like the UK. She just doesn't get that BCBS have been trying to kill her off for years because she's costing them too much. And they may accomplish that yet. One day she might just open another denial of payment letter and just drop dead on the spot of a cerebral haemorrhage.

[rateyes]

8. your family needs to call the local newspaper

[RyanPsych]

33. If it gets that far

we will.

[pa28]

9. Who do you talk to when the "regulators" are actually industry cheerleaders.

Unfortunately your brother might have to rely on the legal system to sort this out and I'm guessing he's short of money. Who has the advantage here?

[obxhead]

12. So glad we could mandate this broken system to guarantee the

continued and expanding profitability of it.

[RyanPsych]

29. Amen

Why actually fix the problem?

Just tweak it and give it a shit load of more money!

[anneboleyn]

55. Amen, seconded!

[HipChick]

13. I had to appeal my claim...get the media involved, start with local media sources

and if you are comfortable go national..these companies dislike negative claim

[likesmountains 52]

14. Your parents need to get the hospital and the surgeon to appeal..just ask them.

It is in the hospital and the MD's best interest ( they'll get paid) to do this.

[DeadEyeDyck]

17. My Aunt works for Met Life as a Claims approver

She said they routinely and blindly reject claims. It is to root out bad claims that won't resubmit. She said if you resubmit, it will probably be approved without issue.

[dflprincess]

25. They also do it because they know most people won't fight a rejection

of a valid claim through to the bitter end. The insurance company just keeps stonewalling until their victim gives up.

[RyanPsych]

30. how sick is that?

How do these people sleep at night?

[Historic NY]

20. Tell the hospital to re-submit...they can get around anything...

including double & triple billing.

[The Unawriter]

31. Shit like this REALLY pisses me off

Insurance companies, live up to your fucking obligations or get out of the business!

[RyanPsych]

32. When you get that rich

you no longer have obligations

only a few days of bad press

[RyanPsych]

34. My mom is thankful for all your suggestions DU!

I'm in town visiting and I've been sharing your insights and suggestions with her.

Thanks!:yourock:

[Glimmer of Hope]

35. Initially denying a claim is one of the many practices BCBS tries to

pull on the insured. I have been through this several times with them over the past few years and after a lot of nonsense, they eventually pay for claims. They would not approve a surgery I needed until the day before my surgery and continued to haggle with my surgeon's office after my surgery.

THey will deny claims, loose claims, send claim checks with an incomplete address, deny coverage for certain prescriptions, etc. I think they intentionally do this to create aggravation (easy to do when you are not well) and to take advantage of the uninformed insured assuming a certain percentage will give up and not push them. They know exactly what they are doing.

[gvstn]

37. Ditto

The first time Blue Cross denied payment for an ER visit $700, I paid the bill thinking, "well I guess that isn't covered".

The next time I got such a refusal, I put up an argument and they paid the bill. Not much of an argument other than the ER was the appropriate place to go and I needed a medical evaluation. The hospital resubmitted and I never heard another word. I really think they refuse claims hoping people won't question it--if even 20% let it go, as I did the first time, they make more money.

Fight it. Nobody volunteers for appendix surgery. Your brother's doctor said it was medically necessary and he had the surgery performed. He was in no position to question the doctor/surgeon's advice. (Most likely no time for a second opinion. Usually, appendix problems are acute and need immediate attention.)

Ask the hospital to resubmit then if refused...Let BCBS DETAIL the refusal and ask your brother's doctor for advice. They will eventually pay if my experience is any indication.

[anneboleyn]

56. This sh*t is really evil, isn't it? And it is going on everywhere, with every private insurer.

[Glimmer of Hope]

58. I just noticed that I haven't received a claim check that they

processed two months ago. It was probably "lost" in the mail.

[Hugabear]

36. Health insurance is nothing more than legal organized crime

It's a huge racket. They take your money, then have an army of adjusters and "experts" to figure out how to deny you the services they're supposed to provide.

It's hilarious listening to right-wingers come up with reasons they oppose government-run health care. Bureaucrats making health-care decisions, rationing, etc - things that private health care is ALREADY DOING.

[Maru Kitteh]

39. Is berating the poster is an appropriate action here?

Try this next time - offer a bit of support or advice or even a kind wish - AND THEN worry about yourself, your thoughts, your point, your agenda.

[Hugabear]

40. I wasn't berating the poster

I was making a general statement - that people need to realize that health insurance is nothing more than a racket. Unfortunately, stories like the OP occur far too often.

I can see how you might have possibly misinterpreted my post, so I'll edit it.

[Maru Kitteh]

41. That's a nice thing to do. It do completely agree with your point, too. n/t

[Newest Reality]

38. What is wrong with this country?

Self delete!

[99th_Monkey]

42. These guys are also trying to foist an annual rate hike of like 22% on Oregonians

who are pissed and making noise about it too on local media.

[Scuba]

44. Of course they do. They're not into the business of paying claims. n/t

[1monster]

45. I don't know your details or the insurance wills/won'ts in the policy, but check them!

If there is no reason for them to hide behind and not pay, threaten them with a "failure to show good faith" law suit. They will usually have a change of heart, blame the refusal on some misunderstanding and pay up.

If they don't pay up, consult a lawyer and go for it if you have a case.

Not only could the insurance company end up having to pay for the medical expenses incured, but they could also have to pay for the plaintiff's legal fees and punitive damage awards.

An famous car insurance insurance company with a history of cute commercials refused to pay the $50,000 top award for an tragic accident which resulted in serious brain injury when the insured backed over a girl ended up having to pay a $17,000,000 when the insured and they were sued by the girl's parents.

[otohara]

46. Start writing letters ... Cc your congressman

Or woman

[Gin]

47. maybe it was the end of a quarter and they had to make their numbers...

re-submit it...it's all about the money and share holders. (IMO)

[glinda]

50. Every BCBS in the Country should be investigated. BCBS is corrupt to the core.

[vssmith]

51. How would BCBS ever make money if they paid all these frivolous

claims. People just expect too much. Didn't you ever read Ayn Rand.

[StarsInHerHair]

57. well a lumpectomy cost $80,000, back in the 1970s I had my tonsils taken

out & it didn't cost $30,000 like it might now, it cost maybe $800. Thank Reagan & the Other Right for letting this happen, letting them push & push for this to become reality.