First off, they tried to deny approval for the surgery as they deemed it not medically necessary. It was a surgery to correct a growth that did not align with my child’s genetic sex. In the policy manual, they will approve “gender affirming surgery.” How is removing a growth that does not align with their genetic sex not “gender affirming surgery?” They repeatedly denied the surgery both times it was scheduled and only finally approved it 24 hours before surgery and only after one of those peer consultations we’ve been hearing about. Fast forward to billing and 5 months after they are refusing to pay the surgeons fee. I called BCBS 6 weeks ago and spoke with someone for 15 minutes who said there was an obvious problem with the denial and she would fix it and the bill would be paid, I just needed to affirm on the phone that I have no other health insurance. I did so and we completed the discussion.
Well, I got another bill and it’s about to go to collection. Mind you, they have paid all but $1166 of a $62,000 bill (f’ng completely outrageous) and they are dragging this out. I called again and this time, whoever I got is taking their sweet time helping me. They claim they can’t find the claim, this takes 15 minutes, then the guy sends it for review by the “claims department” this takes nearly 45 minutes for him to affirm that the claim is fucked up because they say I need a Medicaid denial when all I need to do is affirm I have no other health insurance which I did online while on the phone. He spends a lot of time saying I’m asking for an exception to their rules. Of course I’m not because most of the bill has been paid without this additional paperwork they want from Medicare, which I do not have and we go back and forth about this. He also wouldn’t let me do the verbal verification over the phone which is also possible. The whole encounter was 1h17m and I still feel like this guy was fucking with me. He told me at one point he had a whole department of 3 people researching my issue. I call BS and think he was fucking with me. I want to call next week and lodge a Complaint against Sergio and his inappropriate treatment of my inquiry. I would appreciate any guidance as I am at my wits end of why I have to justify that I don’t have Medicaid when most of the money has already been paid out for this surgery.
He was fucking with you.
Their quarterly bonus is directly tied to how much they ~
deny~ save the company by making you give up.cigna
So the majority of the bill was paid except for $1,166.00. And this remainder is owed to the surgeon? Is this correct? If so it sounds to me like “they” didn’t have the surgeon under their contract where the doc is supposed to write off a portion of his or her fee. The whole payment system for insurance is convoluted. Patients get balance billed all the time, cause the system is greedy bass turds.
Insurance companies write contracts with different medical providers. The insurance company promises to pay a portion of a service called the allowed amount & then the patient’s coinsurance or copayment, which is suppose satisfy the negotiated fee with the surgeon. Trouble comes in when the doctor raises their fee - contract expires or they have to get a non-contracted doctor to do the surgery. The patient gets squeezed to pay the balance. It is called balance billing. The health insurance will only pay their allowed amount. The surgeon wants full fee.
Try talking to a different customer service rep. Unless your health insurance contract says you must pay the balance billing above your coinsurance amount.
Might be good to get a lawyer to review the situation & write a letter.
My mother recently won an epic battle with United Healthcare over paying for a mamogram. It took years and many phone calls. She had the time and she was pissed off,so she didn't give up.
If you have the money and don't have the time just pay the bill. Life is to short to waste it on shit like this.
Wisdom ! Totally agree . Ins paid over 60 K balance is less then 2 K that’s actually some good ins .
Yes i had to pay twice that recently for a hernia operation, lucky for me the nurse admiting me saw they were billing for inpatient and changed it to outpatient and cut my bill in half. All that is hidden in their billing codes,I never would have caught the difference.
File a grievance or appeal for the claim. You should be able to do it through the online messaging in your account. You have to say "this is an appeal". I have not been able to get a hold of them by phone since they recently changed their extensions and when I do the person has no clue what they're doing and say I need to jump through all these hoops. If are able to get a person on the phone, ask to speak to a supervisor who can solve your problem directly.
This sounds exactly like the “American Home Sheild” insurance policy realtors always try to get you to buy. Our seller provided one and we tried to use it for the ac unit that went out. The company we hired to repair it laughed when we said we had that. They want to talk to the repairman for hours holding up repairs and asking about used or alternative repairs. The repairman said they WILL do it but charge US an additional 200/hr for spending time on the phone and that they NEVER approve the repair. It’s a scam!
First ask for an itemized bill for the whole balance. If they can’t prove the charge then collections can’t collect. If they send it anyway, this is a golden ticket.
Then LET IT GO TO COLLECTIONS! It cannot hurt your credit score, it’s the law now. Tell them you are waiting on an itemized bill because the dr can’t tell you what the charge is for and you won’t pay it without knowing. They will have to research and call you back which buys you time. They will stop trying to collect if it’s not a legit charge. If it is a legit charge they will call you to collect. My advice is don’t take the collections call until you can afford to pay at least 50% on the spot. I’ve done this and had my bill reduced by 50%. You can drag it out for months.
I’ve done this several times and once got an entire child birth, delivery and hospital stay at no cost because they couldn’t prove part of my bill when contested.
FILE COMPLAINT WITH STATE INSURANCE COMMISIONER in addition to the above
^^ THIS! Also; always take good notes (date, time, who you talked to and what they said).
I fondly call the process "the art of constructive b!tch!ing". And yes, it absolutely IS an art form!!
Pay the balance and consider it the cost of avoiding enough anger-stress and red tape to equate to an unexpected vacation. I have found legal things to be hideous passages in life that were debilitatingly stressful, honestly.
You are in the right, but sometimes that isn't what matters the most.