Appealing health insurance claim denials - Blue Cross Blue Shield preventative

[ac]

Hi All

I keep having trouble with BCBS denying services that are preventative in nature.  For example:  finger prick tests at a child's routine check up, urinalysis at a check up, hearing screening for a newborn.  BCBS keeps applying their contractual rate, not paying it, and so the doctor keeps billing me.  My plan says it covers preventative services.

Has anyone appealed these sort of denials?  Any useful advice?

[mxt0133]

Unfortunately preventative care or services fall under a very specific list of procedures.  Even though they might be preventative in nature, if it is not in a list of procedures that your insurance covers then they will not pay for it.

You need to find that list or check with you BCBS before you get any service or procedure done to make sure it is covered 100% under the preventative care.

[ac]

Is this a relatively recent change?  When we had a baby in 2013 and had United Healthcare, they took care of all sorts of services, and we didnt pay many bills.  Now its the opposite.  Its also BCBS, and I'm not sure if its the +3 years or the different insurance company. 

[forummm]

There are only certain services that are included in the coverage without cost sharing benefit. You can find them here:

www.cdc.gov/prevention

Hearing screening for a newborn is there and should definitely be covered. Finger pricks and urinalysis are generally not, with some exceptions (potentially for diabetes screening and bacteriuria during pregnancy, respectively).

[Dee18]

If you have BlueCross through an employer, check your policy to see what is covered.  I was told that because my insurance was "grandfathered in" it does not have to meet all the requirements of Obamacare for preventive care.  (I don't even know for sure if that is correct.) but Blue Cross now has a pretty good website where I can enter my policy number and check to see what preventive care is covered, as well as which drugs are covered in full.

I have appealed denials, I think three times, and eventually BC paid them all.  For the biggest one I told the doctor and she resubmitted it with a slightly different code. 

[Tom Bri]

If you have BlueCross through an employer, check your policy to see what is covered.  I was told that because my insurance was "grandfathered in" it does not have to meet all the requirements of Obamacare for preventive care.  (I don't even know for sure if that is correct.) but Blue Cross now has a pretty good website where I can enter my policy number and check to see what preventive care is covered, as well as which drugs are covered in full.

I have appealed denials, I think three times, and eventually BC paid them all.  For the biggest one I told the doctor and she resubmitted it with a slightly different code.

Grandfathered plans do not have to abide by Obamacare.

Also, the list of covered services under Obamacare is very specific. Your insurance company can be as hard-nosed as they like about that. Some will cover things not specifically listed, others go strictly by the list. And it is an odd list. I have the .gov website bookmarked on another computer. I'll post the link here when I get it running.

Call the insurance company and see if they will explain exactly why each code is being denied. You may have to call more than once, as some reps are more helpful than others. If they say it is a non-covered service, you are probably out of luck.

but if they say it was not billed as routine preventative, you may be able to get your provider to rebill it with a corrected claim. In that case, call the provider's billing office and have them get the ball rolling, there are several steps they need to complete. First, they contact the Dr and ask if he will change coding. If so, he has to do that. Then, billing will create the corrected claim and resubmit it. They should include copies of the office records for that date of service in order to substantiate the changes.

[forummm]

If you have BlueCross through an employer, check your policy to see what is covered.  I was told that because my insurance was "grandfathered in" it does not have to meet all the requirements of Obamacare for preventive care.  (I don't even know for sure if that is correct.) but Blue Cross now has a pretty good website where I can enter my policy number and check to see what preventive care is covered, as well as which drugs are covered in full.

I have appealed denials, I think three times, and eventually BC paid them all.  For the biggest one I told the doctor and she resubmitted it with a slightly different code.

Grandfathered plans do not have to abide by Obamacare.

At least with respect to the preventive services provision. There are a few (but not many) provisions that they do have to follow.

[ac]

Thanks all

My BCBS plan says preventative means U.S. Preventive Services Task Force recommendations and American Academy of Family Physicians recommendations.  It is definitely an odd set of lists.  What's strange is that I've seen a version of the list that shows Hearing screening as currently inactive, but I just looked it up again, and its listed.  Hurray for ammo!

I'm going to think of it like this:  the money's gone.  I've got my payment plan set up on auto pay to the hospital.  But I'll call and appeal etc and try to view it as a game.  Whatever money I save is free money to me.  Then maybe I'll stop being so pissed and losing sleep over this stuff.  (Its not just charges for hearing screening that upset me).

Dee18:  please advise on how to approach the appeals process 

[ac]

I keep hearing the "grandfathered in" wording.  at first I assumed not being under the obamacare umbrella would be a bad thing since obamacare is supposed to help.  But sheesh as far as these preventative services go, we had thousands of dollars worth of services taken care of in 2013 before switching plans to something under obamacare.  Oddly, in my experience, obamacare has meant not being nearly as well covered for preventative stuff (prenatal ultrasounds etc).

Dont take this as wholesale anti-obamacare rhetoric.

[forummm]

Thanks all

My BCBS plan says preventative means U.S. Preventive Services Task Force recommendations and American Academy of Family Physicians recommendations.  It is definitely an odd set of lists.  What's strange is that I've seen a version of the list that shows Hearing screening as currently inactive, but I just looked it up again, and its listed.  Hurray for ammo!

In addition to the USPSTF and AAP (it's American Academy of Pediatrics, not AAFP), ACIP and the Advisory Committee on Heritable Disorders in Newborns. The ACHDN USP calls for newborn hearing screening. As does the AAP. If you have a nongrandfathered plan, it must be covered by law.

http://www.hrsa.gov/advisorycommittees/mchbadvisory/heritabledisorders/recommendedpanel/index.html

AAP's screening schedule:
https://www.aap.org/en-us/Documents/periodicity_schedule.pdf

[COlady]

Thanks all

My BCBS plan says preventative means U.S. Preventive Services Task Force recommendations and American Academy of Family Physicians recommendations.  It is definitely an odd set of lists.  What's strange is that I've seen a version of the list that shows Hearing screening as currently inactive, but I just looked it up again, and its listed.  Hurray for ammo!

I'm going to think of it like this:  the money's gone.  I've got my payment plan set up on auto pay to the hospital.  But I'll call and appeal etc and try to view it as a game.  Whatever money I save is free money to me.  Then maybe I'll stop being so pissed and losing sleep over this stuff.  (Its not just charges for hearing screening that upset me).

Dee18:  please advise on how to approach the appeals process 

Are you saying that you have your HSA set up to autopay?? My husband's was set up to autopay by his company without our consent. The HSA autopaid a bunch of bills that I would've negotiated and I was pissed. I talked to his benefits department and they admitted that they accidently set his account up for autopay. Why would you want to autopay??? Once they have payment your negotiation power is completely gone.

[ac]

Its sending $25 checks each month to the hospital.  Its not a blanket "I'll pay anyone anything anytime."

[JoJo]

I went out to dinner recently with a friend of a friend who is a medical billing manager.    She said that in the many pages of Obamacare they failed to include ANY blood tests in the definition of preventative care (even those we think of as preventative such as blood sugar, cholesterol, etc).  As a result, some of the insurance providers (she specifically mentioned the "Blues") no longer include any blood test in preventative as it obviously keeps their premiums lower.  Other companies still include blood tests (I recall she mentioned United HC as an example).

She gets calls on this all the time and people are frustrated because "these were always covered before".

[forummm]

I went out to dinner recently with a friend of a friend who is a medical billing manager.    She said that in the many pages of Obamacare they failed to include ANY blood tests in the definition of preventative care (even those we think of as preventative such as blood sugar, cholesterol, etc).  As a result, some of the insurance providers (she specifically mentioned the "Blues") no longer include any blood test in preventative as it obviously keeps their premiums lower.  Other companies still include blood tests (I recall she mentioned United HC as an example).

I don't think this is correct. Maybe she was saying something else but you misunderstood. The regulations make it pretty clear that, for example, cholesterol testing (for certain age groups) is a covered preventive service, so they have to pay for it. I don't know of any way this could be accomplished besides a blood test. Diabetes testing could be accomplished a couple ways, so they have options. But usually it's a blood test. If you could provide evidence that the Blues are not covering cholesterol testing as a preventive service, I would very much like to see that.

[Tom Bri]

I went out to dinner recently with a friend of a friend who is a medical billing manager.    She said that in the many pages of Obamacare they failed to include ANY blood tests in the definition of preventative care (even those we think of as preventative such as blood sugar, cholesterol, etc).  As a result, some of the insurance providers (she specifically mentioned the "Blues") no longer include any blood test in preventative as it obviously keeps their premiums lower.  Other companies still include blood tests (I recall she mentioned United HC as an example).

She gets calls on this all the time and people are frustrated because "these were always covered before".

Yeah, not quite correct. My insurance tried to deny the blood draw for the cholesterol check. I called and just said, how can you check the cholesterol without doing a blood draw? For some reason, they were billed separately, so the insurance didn't connect the dots. They paid it once I pointed it out. Cholesterol checks are covered under Obamacare.

[forummm]

I went out to dinner recently with a friend of a friend who is a medical billing manager.    She said that in the many pages of Obamacare they failed to include ANY blood tests in the definition of preventative care (even those we think of as preventative such as blood sugar, cholesterol, etc).  As a result, some of the insurance providers (she specifically mentioned the "Blues") no longer include any blood test in preventative as it obviously keeps their premiums lower.  Other companies still include blood tests (I recall she mentioned United HC as an example).

She gets calls on this all the time and people are frustrated because "these were always covered before".

Yeah, not quite correct. My insurance tried to deny the blood draw for the cholesterol check. I called and just said, how can you check the cholesterol without doing a blood draw? For some reason, they were billed separately, so the insurance didn't connect the dots. They paid it once I pointed it out. Cholesterol checks are covered under Obamacare.

I have heard of this happening. As in most things, you have to be your own advocate. We had an $850 bill that we shouldn't have gotten a few months back. Really, there was no excuse for it. But I think they are hoping you'll just pay it. And then it's pure profit for them. We called them on it and it went away.

[Dee18]

For the one who where my daughter's gyn did a bunch of lab tests, I called BC and went over each item and why it was denied. BC said the code was basically that the doctor had done it as "routine" rather than for any medically necessary reason.  I then called the dr's office, several times.  They eventually submitted it under a code acceptable to BC.  One of the other times that BC said the dr visit wasn't covered I directed the person on the phone to where my policy said I could get a second opinion before surgery.  The third occasion had to do with a chest X-ray for my doctor that was ordered by a doctor who they said was "in plan" for me and "out of plan" for my daughter. This was because the doctor was at my employer.  I was told by BC and the clinic that the clinic was in plan for her, but it turned out that because she was over 18 it wasn't in plan for her.  (I had not told them her age; they had just assumed she was a minor.) I just kept calling on that one, truthfully insisting that they had told me it would be in plan, and finally the phone rep said they would cover it.  I really think persistence just won.

My daughter's pediatrician was part of the local children's hospital and they had a special deal with BC where they made the call on what was covered...I'm not sure if those relationships still exist, but it was great.

[Zamboni]

BCBS . . . ugh. They were actually issued a gigantic fine by my state a couple of decades ago (and maybe more recently as I don't follow that news closely) for not paying for things they were supposed to cover. Read more if you care to find out how I have learned to combat it.

I had twins at a hospital that was "in network", but some of the doctors who worked at the hospital were apparently "out of network." BCBS was supposed to pay anyway, and they certainly were supposed to pay for care for both infants and not reject everything as "duplicate billings," but the runaround is their game. That scene from the movie The Incredibles pretty much nails it. Anyway here is the game plan:

Document, document, document. Every time you call either the doctors office or BCBS, write down the date, time, and name of whom you speak with. Repeat their name to them and make sure you spell it correctly. Write down what they say their action will be or what needs to be done (most often this will be to refile the claim a certain way, but sometimes they say they will call the other party to resolve it.) I used to go round and round with them 3-4 times. That gets old. In the most ridiculous case, I went round and round more than 6 times over many months with BCBS who keep alternating their reasons (literally switching back and forth between two technicalities about how it was filed) for not paying the anesthesiologist for my C-section. In that case I ended up sending my stack of documenting paperwork to the state department of insurance. My state has an online complaint form and then you just mail in supporting documentation; you might even be able to scan and attach it online now. They called me to say they were investigating, and BCBS paid the claim within 2 weeks of the investigation opening.

I am at the point where I just call the insurance once and the doctor once. I keep my notes carefully. If that doesn't resolve it, and I am certain it should be covered, then the next time I get a bill or statement of benefits denying a claim, then I send the insurance company a copy of the most recent nonpayment statement with a written letter explaining that "I have made a good faith effort to resolve this" and that "If this does not get paid within the next 30 days, then I will file a complaint with the state Department of Insurance." That leads to payment 100% of the time so far.

Good luck!

[ac]

This is exactly the help I was hoping to get!

[Tom Bri]

Zamboni basically nailed it. Until a month ago I worked in claims for an insurance company, fielding calls exactly like this. When you call, write everything down! Time/date/names. If someone tells you something, write it down. The company documents every call, and we also recorded every call, so if there was a dispute over what was said, we had it covered.

However, a lot of claims are not paid for the very good reason that the contract you signed does not include that service. Make sure you read your insurance contract, particularly the "BENEFITS' sections, and the "EXCLUSIONS" sections.

Lots of people told me they were contacting their state insurance commission. Makes no difference whatsoever, if the service is not covered. We still won't pay.

I would say that the great great majority of unpaid claims are due to the provider incorrectly billing, for example billing a yearly physical wellness exam as a sick office visit. Doctors suck at billing. Really. We also made mistakes however, and a big part of my job was making sure those mistakes got corrected. It was actually kind of fun to call people back to tell them we were mailing them a check.

[Bourbon]

Zamboni basically nailed it. Until a month ago I worked in claims for an insurance company, fielding calls exactly like this. When you call, write everything down! Time/date/names. If someone tells you something, write it down. The company documents every call, and we also recorded every call, so if there was a dispute over what was said, we had it covered.

However, a lot of claims are not paid for the very good reason that the contract you signed does not include that service. Make sure you read your insurance contract, particularly the "BENEFITS' sections, and the "EXCLUSIONS" sections.

Lots of people told me they were contacting their state insurance commission. Makes no difference whatsoever, if the service is not covered. We still won't pay.

I would say that the great great majority of unpaid claims are due to the provider incorrectly billing, for example billing a yearly physical wellness exam as a sick office visit. Doctors suck at billing. Really. We also made mistakes however, and a big part of my job was making sure those mistakes got corrected. It was actually kind of fun to call people back to tell them we were mailing them a check.

Most of this.

Also you say they are applying their discounted rate and then not paying.  Were there any specific codes or messages that BCBS sent to you?  Was this actually denied or did they just apply it to your deductible?  Lots of small things could have gone wrong, and it usually requires a bit of detective work to get to the root of the issue.

[ETBen]

FYI, BCBS is not one company across the US.  There are 36 Blues and FEP (federal employee).  And each Blue offers thousands of policy variants based on what your employer chose (or if you purchased on the ACA exchange).

ACA is something I know well.  Preventive test that are required to be covered are on the website.  Other tests your plan may cover can be determined by calling Customer Service.

Otherwise, it's likely your Physician is billing it incorrectly (and probably doesn't even know it).  It's not that BCBS didn't pay the claim.  They didn't pay the claim bc the Physician didn't submit for reimbursement correctly, so now he/she is balance billing you. 

I would contact the CSR to determine the correct benefits.  Keep asking for a manager until you get an answer that seems correct or the person really sounds like they know what they are talking about (if they don't at first). 

Then tell the Physician office and refuse to pay until they submit correctly.  They are contracted to accurately submit for reimbursement and it is their responsibility.  Its confusing, its complex, I feel for them.  But it's part of doing business and there are plenty of sources for them to figure out how to do it correctly.   

[Tom Bri]

This website has the prev bene listed:
http://www.priorityhealth.com/provider/manual/billing-and-payment/services/preventive-care/preventive-service-codes

And I am attaching a pdf that also helps.

[StarBright]

BCBS . . . ugh. They were actually issued a gigantic fine by my state a couple of decades ago (and maybe more recently as I don't follow that news closely) for not paying for things they were supposed to cover. Read more if you care to find out how I have learned to combat it.

I had twins at a hospital that was "in network", but some of the doctors who worked at the hospital were apparently "out of network." BCBS was supposed to pay anyway, and they certainly were supposed to pay for care for both infants and not reject everything as "duplicate billings," but the runaround is their game. That scene from the movie The Incredibles pretty much nails it. Anyway here is the game plan:

This happened to us with BCBS too! My husband's appendix burst and as they were wheeling him into emergency I even made a good faith effort to make sure they got someone who took our insurance. I was told that because it was an emergency situation of course insurance would cover it.

Guess who got a separate "out of network" bill for thousands of dollars a month later? The anesthesiologist was out of network and we had a whole out of network, 10k deductible amount that we'd never touched (of course we try to always stay in network). Took about six months and many hours of my life to resolve.

I've found that even trying to get pricing up front and confirming it with both insurance and Dr doesn't always work. I booked a couple of appointments this year because I had already hit my high deductible and figured I'd get some basic bloodwork run because I was suspecting that I was anemic and B12 deficient. I confirmed with both BCBS and the Dr's office that they accepted my insurance and were "in network" and that I had, in fact, hit my deductible.

I just got a bill yesterday for the full negotiated rate because it was out of network. I have started the process of phone calls this morning. It should not take hours of my life to get billed the correct amount for a check up and blood panel.

[forummm]

This website has the prev bene listed:
http://www.priorityhealth.com/provider/manual/billing-and-payment/services/preventive-care/preventive-service-codes

And I am attaching a pdf that also helps.

Even in this I notice a stated coverage provision that likely violates the law. The colon cancer screening polyp pathology (page 3 of the PDF) is still required to be covered when the polypectomy results from a preventive colonoscopy. The administration has even clarified this in subregulatory guidance because polypectomy is inherently part of the preventive colonoscopy procedure.

[Zamboni]

Otherwise, it's likely your Physician is billing it incorrectly (and probably doesn't even know it).  It's not that BCBS didn't pay the claim.  They didn't pay the claim bc the Physician didn't submit for reimbursement correctly, so now he/she is balance billing you. 

Um, yes and no.

When you have two children born on the same day to the same parents but with different names and different social security numbers, otherwise known as twins, is it reasonable to have a system that automatically rejects one set of claims every single time as a duplicate claim even though you can see right on their paperwork that the filings were for the different names? Because that was what I was dealing with. Every check up, every immunization . . . seriously I can see it happening once but over and over for years? Because that was what I dealt with when we has BCBS. As soon as we switched insurance providers, the problem disappeared.

While I am generally happy to accept ineptitude as a benign excuse, it became very clear to me that in my case BCBS was also intentionally not paying the bills or the anesthesiologist. The alternated back and forth between "incorrect procedure code" and "incorrect dose code" (or something right along those lines.) I kept all of the statements of benefits with their reasons for rejections listed, and when I went back through them I could see the pattern:  procedure code . . . dose code . . . procedure code . . . dose code . . . procedure code . . . does code. . . procedure code. I had called each time and asked for the exact codes that needed to be used, and then called the doctor's billing office to give them that information. At this point I am confident that the billing office was following the instructions and following up with another bill with the particular codes I had been told would work this time.

BCBS paid promptly when DOI opened the investigation. Later that same year they were fined $1.8MM by my state for not paying a huge number of claims.

That was more than a decade ago and now our insurance commissioner is saying that there have been more than 10,000 calls and complaints (with over 1700 formal written complaints filed) against BCBSNC just this year alone. And that was reported at the end of March, so basically we are talking about the first quarter of this year.

To be fair, I haven't had such a bad experience with any other insurance provider.

[ac]

Zamboni basically nailed it. Until a month ago I worked in claims for an insurance company, fielding calls exactly like this. When you call, write everything down! Time/date/names. If someone tells you something, write it down. The company documents every call, and we also recorded every call, so if there was a dispute over what was said, we had it covered.

However, a lot of claims are not paid for the very good reason that the contract you signed does not include that service. Make sure you read your insurance contract, particularly the "BENEFITS' sections, and the "EXCLUSIONS" sections.

Lots of people told me they were contacting their state insurance commission. Makes no difference whatsoever, if the service is not covered. We still won't pay.

I would say that the great great majority of unpaid claims are due to the provider incorrectly billing, for example billing a yearly physical wellness exam as a sick office visit. Doctors suck at billing. Really. We also made mistakes however, and a big part of my job was making sure those mistakes got corrected. It was actually kind of fun to call people back to tell them we were mailing them a check.

Most of this.

Also you say they are applying their discounted rate and then not paying.  Were there any specific codes or messages that BCBS sent to you?  Was this actually denied or did they just apply it to your deductible?  Lots of small things could have gone wrong, and it usually requires a bit of detective work to get to the root of the issue.

For the blood tests what keeps happening is:  my kids' pediatrician does complete blood count (cbc), sends a claim to bcbs of sc for $68.  bcbs of sc says its not covered as preventative, the contractual rate is $17.  then the pediatrician bills me for $68.  Once the pediatrician offered to make it 50% off if I paid quick.  Then I call bcbs sc and talk to a nice lady who covers it as preventative.  she doesn't work there any more though.

same story for urinalysis but different prices. 

shouldn't my pediatrician at least bill me the $17 allowed amount rather than the $68 list price?

and yes indeed, physician offices suck at billing.  I always get the feeling its just a bunch of numbers on a page to them, and they use little effort to double check logic. 

[forummm]

Zamboni basically nailed it. Until a month ago I worked in claims for an insurance company, fielding calls exactly like this. When you call, write everything down! Time/date/names. If someone tells you something, write it down. The company documents every call, and we also recorded every call, so if there was a dispute over what was said, we had it covered.

However, a lot of claims are not paid for the very good reason that the contract you signed does not include that service. Make sure you read your insurance contract, particularly the "BENEFITS' sections, and the "EXCLUSIONS" sections.

Lots of people told me they were contacting their state insurance commission. Makes no difference whatsoever, if the service is not covered. We still won't pay.

I would say that the great great majority of unpaid claims are due to the provider incorrectly billing, for example billing a yearly physical wellness exam as a sick office visit. Doctors suck at billing. Really. We also made mistakes however, and a big part of my job was making sure those mistakes got corrected. It was actually kind of fun to call people back to tell them we were mailing them a check.

Most of this.

Also you say they are applying their discounted rate and then not paying.  Were there any specific codes or messages that BCBS sent to you?  Was this actually denied or did they just apply it to your deductible?  Lots of small things could have gone wrong, and it usually requires a bit of detective work to get to the root of the issue.

For the blood tests what keeps happening is:  my kids' pediatrician does complete blood count (cbc), sends a claim to bcbs of sc for $68.  bcbs of sc says its not covered as preventative, the contractual rate is $17.  then the pediatrician bills me for $68.  Once the pediatrician offered to make it 50% off if I paid quick.  Then I call bcbs sc and talk to a nice lady who covers it as preventative.  she doesn't work there any more though.

same story for urinalysis but different prices. 

shouldn't my pediatrician at least bill me the $17 allowed amount rather than the $68 list price?

and yes indeed, physician offices suck at billing.  I always get the feeling its just a bunch of numbers on a page to them, and they use little effort to double check logic. 

CBC and urinalysis are not covered in the preventative service benefit. Just get used to that. Not everything that one thinks of as being preventative is included. Many of those things are actually not necessary or very useful or backed by evidence, and that's why they are not included.

Is your doctor in-network? If so, then they are contractually obligated to take whatever your insurer pays them (i.e. $17) and they are not allowed to balance bill (ask you for the difference between insurer payment and their desired charge--i.e. $51). Balance billing violates their contract with your insurer if they are in-network. If you choose to go to an out-of-network provider, then you have to negotiate with the provider.

[ac]

Yes, in network.  I'll try using the words "contractually obligated" the next time they send me a bill for $68. 

The claims lady at bcbs sc yesterday told me bcbs used to cover lots of intuitively preventative procedures, but when aca came through designating necessary preventative procedures insurance companies had to cover, bcbs said "oh...well if that's all preventative means, that's all we'll cover."  so things like cbc and urinalysis coverage went away unless you pay extra for preventative plus plans etc.

[I'm a red panda]

I am currently going through an appeal myself.

From the people I've talked to who have had to do the same thing as me, writing the state insurance commission seems to be the only way to get anything done.

And depending on which state you are in will change how successful that is.

[forummm]

Yes, in network.  I'll try using the words "contractually obligated" the next time they send me a bill for $68. 

Or get a more ethical doctor.

[Tom Bri]

Yes, in network.  I'll try using the words "contractually obligated" the next time they send me a bill for $68. 

The claims lady at bcbs sc yesterday told me bcbs used to cover lots of intuitively preventative procedures, but when aca came through designating necessary preventative procedures insurance companies had to cover, bcbs said "oh...well if that's all preventative means, that's all we'll cover."  so things like cbc and urinalysis coverage went away unless you pay extra for preventative plus plans etc.

If a claim is DENIED the provider can balance bill. Only if the claim is allowed (even if nothing is paid directly and only the discount applies) must the provider accept the insurance company's discount amount.

CBC is NOT preventative under the ACA.

[ohsnap]

Yes, in network.  I'll try using the words "contractually obligated" the next time they send me a bill for $68. 

...

I've been balance-billed twice in the last year.  Both times I wrote letters, with attached EOBs, and informed the providers that their contract with the insurance company prevented them from attempting to collect the remaining amount.

Both times, the next communication I got from the providers was a final bill warning me that I was about to go to collections!

And both times, a call to the insurance company (UHC last year, BCBS this year) quickly got it fixed.  Apparently providers don't care when the patient contacts them, only when the insurance company does.  So I won't bother any more with letter writing if it happens again; I'll call the insurance company and let them deal with it.

[ac]

The good news:  I filed a complaint with the SC Department of Insurance last week, and 6 days later BCBS called me.  They apologized for all the trouble and said they will pay the $465 of preventive items for the baby.  Is there anything else I need?  Yes!  I told them.  Yes, I need BCBS to pay for the preventive items on my wife's bill too.

So hopefully the good news will continue to flow.

Here is what I've learned:  as soon as you get crap from the insurance company, file a complaint with your state department of insurance.  Mine was a simple online form. 

[Zamboni]

^Yep.

Glad to hear the good news!

[Jtrey17]

If you have BlueCross through an employer, check your policy to see what is covered.  I was told that because my insurance was "grandfathered in" it does not have to meet all the requirements of Obamacare for preventive care.  (I don't even know for sure if that is correct.) but Blue Cross now has a pretty good website where I can enter my policy number and check to see what preventive care is covered, as well as which drugs are covered in full.

I have appealed denials, I think three times, and eventually BC paid them all.  For the biggest one I told the doctor and she resubmitted it with a slightly different code.

Grandfathered plans do not have to abide by Obamacare.

Also, the list of covered services under Obamacare is very specific. Your insurance company can be as hard-nosed as they like about that. Some will cover things not specifically listed, others go strictly by the list. And it is an odd list. I have the .gov website bookmarked on another computer. I'll post the link here when I get it running.

Call the insurance company and see if they will explain exactly why each code is being denied. You may have to call more than once, as some reps are more helpful than others. If they say it is a non-covered service, you are probably out of luck.

but if they say it was not billed as routine preventative, you may be able to get your provider to rebill it with a corrected claim. In that case, call the provider's billing office and have them get the ball rolling, there are several steps they need to complete. First, they contact the Dr and ask if he will change coding. If so, he has to do that. Then, billing will create the corrected claim and resubmit it. They should include copies of the office records for that date of service in order to substantiate the changes.

As someone who has 20 years in the insurance industry-this is exactly the advice to follow. Change the codes, or appeal.

[ac]

A BCBS claims agent told me she filed an appeal for me and I should receive an answer within 30 days.  That was two months ago.  I asked more than once how the appeal was going and got no answer.

So to be clear for others who take something away from this thread, I disagree with your advice and repeat my own advice: 

As soon as you get crap from the insurance company, file a complaint with your state department of insurance.

It is easier than filing an appeal, and you actually get an answer.  And fast!