Health Insurance Appeals

Oh, I DESPISE BCBS, for this very reason. Good luck to you, because all my dealings with them tell me that you will need it. And let us know what happens...maybe if something worked for you, it will work for me, too.

Only the allowed amount will go towards the deductible. So look at the EOB you received from BCBS to see what amount they allowed on the claim. The difference between the allowed amount and the amount they paid is the amount that should have been applied towards the deductible. The problem is insurance companies have a disclaimer that states they do not guarantee payment and they can change their determinations at any time, etc. Often times they state inaccurate information, but get away with it because of the disclaimer. Look back to the written policy benefit discription. If you don't have a copy you should be able to view it on their website. If the written policy is in agreement with what the representative stated to you then you have reason for appealing to the state, but if not you are out of luck. Also, it's always good to get a reference number for every call you make to them. Feel free to contact me if you have additional questions. Good Luck!

I made a living collecting insurance payments for 10 yrs. BCBS is awful with paying claims. At 1 time, "I" educated BCBS on an incorrect pay practice to chiropractors that went as high as the BCBS execs, and they had to change their pay methods for the entire state of Tx. anyway... understand that BCBS pays claims differently depending on the state you live in. 1st, get a complete copy of your policy's contract with bcbs. You get it when you sign up. See what the "contract" says regarding hearing aids, whether or not they are applied to the deductible, etc... Never settle with speaking to a claims rep. Never settle for just filing your appeals thru the mail. I mean, always ask to speak to the claims rep's supervisor. If you don't like what they say, ask for the supervisor's supervisor. Yes, you want to file a claim with the state board of insurance. Insurance companies hate that. AND the state board HAS to investigate every complaint they get, AND within designated time frames. If you aren't comfortable doing all this, I'd be happy to help you write the letters, make the calls etc... What area do you live in?

I appeal medical claims for a living. Keep appealing, they are banking on you not following thru. Send copies of documentation and tell them you will take your claim to the Texas Dept of Insurance in Austin. Insurance companies hate to have to explain to the Texas Dept of Ins why they are rejecting a claim. They have to respond in a certain time frame. And it them a bad name in the insurance industry. Appeal, appeal, appeal.

Dont even get me started on insurance companies and the scam they run. I have appealed to the state level on two different ocassions and won both, but only because I had the back up paperwork. The insurance board is really cracking down since medical costs are on the rise and scams are run everywhere. I hope you get the same good results I have, but without the bad taste for insurance companies I have :)

S.,

It sounds like the $2000 was your co-pay for the hearing aids, not the deductible. When you spoke to them originally if they told you it would be applied to your deductible, they have to honor that. The state will ask for a copy of the call when you appeal it. Have you heard them play it back for you? If not, call and ask them to play it for you and then record it. If the rep said it on the phone, you win. I fight battles from time to time with my mom's insurance company, so I am familiar with the way they try to word things to confuse people. I also have a background in medical appeals for a few doctors. The insurance commission takes these things pretty seriously so you probably will be okay.

Good luck!
C.

I actually do this for a living. I work in Insurance collections for a large University Hospital.

What I would suggest is to review the explanation of benefits you received from BCBS to see how they processed your claim. Then refer to your benefits booklet you received from your employer.

Regardless of what they advised you when you called, the claim will be processed according to the benefits that are listed and set in their system for your plan. They may have processed the claim correctly and the representative you spoke with gave you the incorrect information.

Unfortunately because they give you a disclaimer when you call, they are not obligated to change the processing of a claim based on what a representative told you.

However if in your benefits booklet it shows specifically for hearing aids that the deductible applies then you need to use this information in your appeal.

Good luck, feel free to contact me if you have any more specific questions.

R.

I do not know much about filing the appeal, but I would suggest getting in contact with you state Commission for the Deaf and Hard of Hearing and asking them for advice. They should have people within their agency that will be able to help you with the wording of your letter and also to help you with any action necessary if the insurance company does not do as they said they would. Also, I do not know if it will help you with this set of hearing aids, but you could also contact your state Vocational Rehab office (in New Mexico it is DVR and in Texas it is DARS, I don't know about your state). They should be able to help you pay for hearing aids if they help you in your job. Good luck.

Definitely go to the state! You gotta stay on the insurance companies. You can also call them back again and talk to someone other than the low man on the totem pole on the other end of the customer service phone number.

Good LUCK! You are going to need it!

Remember to document everything!

Simply put, call a lawyer.

I'm betting they know what they are doing and that it's wrong. Anything you've paid that you can provide receipt of should go towards the deductible. The only thing that will not go toward it would be the co-pay at the doc's office. Anything at all extra should. They are just pushing it until they hope you will just give up. I've even heard people who use to work in insurance say that most things are automatically denied. A denial letter goes out no matter what the issue, even if it is something routine that they will cover. You just have to push...$2000 is too much to let them get away with.

Unfortunately, I have never had to take an appeal this far before but, if you've already appealled it twice, they will probably deny it again, but it is worth the try.

I work for a BCBS rival insurance company and the whole idea of "benefits," is that they provide something for you that, most often, you won't find covered with another insurance company. It's all a rouse to get you to come on board with their insurance company so they offer you something and in fine print, so to speak, say that the deductible and coinsurance is waived or not applied. It just means that the benefit will not be counted toward those numbers so you still have to satisfy them on another level.

Unfortunately, it doesn't matter to them that one of their representatives have misquoted benefits to you. Good luck.

I have worked for the state for over 35 years. When I first started, Blue Cross Blue Shield was the only insurance offered. They were rip off artists at that time & I can see that they still are. I know of some that have won appeals through the state but the process is drawn out & you've already discovered the fact that they will recoup their "losses" by any means necessary. (Charging you the extra $800) I also know of lawsuits against them that were successful. (There's a reason they had to declare bankruptcy and reorganized to come back as BCBS or Health Select)
I wish you the best of luck in your attempt to be treated fairly by this company but would suggest that you switch to a different carrier that is concerned with patient well being and not just making a buck. Pay particular attention to the copays on medical equipment when choosing. If your company has an open enrollment period, there is usually no penalty or waiting period for pre-existing conditions and no Evidence of Insurability is needed.

I am not an insurance expert and I hate to be the bearer of bad news, but in my "insurance experiences" I have found two things

1. No matter what the "help line" people tell you, recorded or not, the insurance company will pay what they have written in the fine print of your policy declarations.

2. The out of pocket $2,000 you paid is just that . . . "maximum out-of pocket" amount (could be a yearly max or a lifetime max depending on your policy). Deductibles and co-pays are seperate things. Some companies call them 1. Co-Pay, 2. Deductible, and 3. "co-Insurance" or out-of-pocket expenses.

Again I am not an HR / benefits master, but that is what I have found in dealing with my Fiance's recent stroke and all the insurance "stuff" that has come with it.

As a psychotherapist, I have had to file with the state to be reimbursed what was owed me. You need to inform BCBS first that you are filing a complaint with the state. Then if that doesn't prompt them to deal with the problem, file your complaint. If you have a legitimate complaint, you will probably get paid. I have been.

C. C. M. MS, LPC, LMFT

I once "heard" that something like 50-70% of claims are kicked back by health insurance companies because they know that the majority of the people WILL NOT hang in there and fight with them. It's really sad that we pay as much as we pay and then have to fight with them. : ( In reference to your situation, read your policy carefully and if you are positive that they "should" have applied it to your deductible, here is what I suggest that has worked for me in times past. I have contacted the State of Texas Insurance Board. (If you are not in Texas, I would think that your state has a similar State agency.) They have often give me guidance as to what to tell the insurance company and of course if all else fails, you can file a complaint with the State and they will handle it for you. It can be time consuming, but I am usually successful. Amazingly, the mere mention of "The State" to an insurance company and they often back down. By the way...the section of your phonebook that has all of the State and Federal numbers can absolutely be your best friend! From Insurance claim problems, to problems getting your medical records, to an unethical retailer...there are numbers that can provide guidance and help in the phonebook. : ) I too have BCBS and besides their rates sky rocketing, I have noticed huge changes in them in the last 12-18 months and unfortunately they are not changes for the better. I know how frustrating it is to be fighting with an insurance company. Good luck!

Are you only talking to the 1-800 people who are only capable of reading from answers 1, 2, 3?

Have you spoke to your benefits coordinator / agent for assistance? At this point I would go that route if at all possible - they may know someone else to talk to for a positive resolution.

Do you also have this in writing from BCBS? That they charged you (gave you a quote) then 'overpaid'? Do you have the info for your policy that shows what's covered & how much? I personally hate BCBS, like most other insurance companies, they don't wanna pay up. You stated you had a transcript of the call, did you happen to record the call on tape? That would be very helpful as 'written' transcripts can be proclaimed as made up in their view of things even though they stated their terms to you before, they'll try anything to back out. If you called & there was a message "this call may be monitored or recorded for quality assurance" may mean they taped it too but they'd probably deny that if you asked about it. You may have to consult w/an atty if this next appeal doesn't go thru. There are attys who will help w/the stipulation that if you don't win the case, you don't hafta pay for their service. It's a shame we have to put up w/companies like this who force us to fight so hard to get what's owed to us. Good luck!!

Don't appeal with the state ...yet. Find a lawyer, one that's upfront about costs and specializes in medical claims. Do the next appeal through the lawyer. If the insurance company contacts you refer them to your lawyer and record/date all calls.

Man, I wish I could offer some helpful advice but this is what BCBS has become. As a midwife, I no longer accept BCBS because the say, in writing even, that they will pay and then after the baby is born they refuse. Even my billing company has passed an office policy not to accept BCBS for any reason. I have heard of doctors who refuse it. It is such a sad scenerio because BCBS used to be the premiere insurance to have. When I was growing up my family had it and it was incredible.
Good luck!

J. Dirmeyer
Midwife