Does anyone work for Blue Cross Blue Shield? Explanation of Benefits Q....?

Question

Plan my wife and I are on: Blue Choise POS 10

My wife is 27 weeks pregnant. She has to go to Labor and Delivery because she had stomach problems, abdomenal cramping, and back pain.

I got an explanation of benefits from 4/5/07 yesterday (4/6/07)
Saying that I am responsible for the charges.

Here is the explanation: The explanation: "You are responsible for these charges because your contract excludes benefits for services provided out of network when they aren't for emergancy care or authorized by the primary care physician or network physician."

Well: plan states 100% coverage as long as facility is in network.

Why does the Explanation of Benefits say that they are not paying for this?????

She is STILL in the hospital, so why did they do an explanation of benefits already??????

oh.... verified that hospital she is staying at is IN NETWORK.

Answer 1

Well, you are on a Point of Service plan which means that you generally would need a referral from your Primary care physician. If you don't have this then you may have to pay for the bills. I would try calling your member services line and explain what is going on, that the hospital is in the network, and you may want to contact her Primary Care Physician to see if you can get approval from them for her treatment elsewhere.

Answer 2

All insurance companies play this game at one time or another. They figure if they can get you to pay the bill, why should they? Payment for charges takes up to 8 weeks or longer, but a denial comes immediately if not sooner!

As long as you notified the insurance about the hospitalization the next business day ( or at least called your PCP if they're not the attending doc in the hospital) to get "authorization" , the insurance doesn't have a leg to stand on. If you didn't call your PCP, call them tomorrow and ask them to call the insurance and give them "prior authorization" - which really isn't prior, but as long as they call, most of the time the insurance backs down.

The other alternative is to call member services at your plan and explain WHY your wife is in the hospital and ask them to reconsider the charges. Sometimes, the idiot who gets the claim (here in NY, they hire college kids to process claims, which BUGS me but that's a whole other story!) looks at the provider wrong - some providers fall under more than one heading, and it effects the way the claim is processed. If they refuse to reconsider the charges, ask them for the appeals process and appeal it formally.

Whatever you decide to do, make sure you notfiy the billing department at the hospital so they don't harass you about paying it. Tell them you're fighting with your insurance and will keep them informed. (Otherwise, you could end up in collection, which is a headache!)

I know this is all a pain the *ss, especially now, but DO NOT back down! Insurance companies count on p*ssing you off so you give up and pay the bill. As long as you do what you're supposed to and stand your ground, they'll lose! If the person you get initally isn't helpful, ask for their supervisior. If that doesn't work, wait ten minutes and call back.

Good luck! I hope your wife feels better.

Answer 3

Verify that the hospital is definitely in network. Also what services are being denied if they are for the professional fees it's possible that the Dr is out of network BUT if she had no choice in who saw her in the hospital that would fall under the umbrella of the in network facility.

Call Blue Cross and question why they won't cover these charges. The csr should be able to appeal it for you to get the charges covered.

Answer 4

First, the phone to ask these questions is on the EOB. These rejections can usually be handled by a phone call from the treating MD who forgot to get authorization, or from your primary, but you have to call BC first and ask what's up. They deny everything they can, and start from there. So ask what you need to reverse this rejection. You can't walk in any facility and get any service without authorization, but usually they will allow postdated authorizations. BE CALM and MATTER OF FACT or they won't help you, is my experience. When all else fails, there is a state insurance board that will step in and help you.

Answer 5

there is no "game" that ins companies play. the fact is, there are tons of claims coming through the door and sometimes the claims have different info than what is housed in the provider file for the ins company. meaning, professional (dr) service comes through w/a diff tax id by the billing company. ins company's computer (not a person) doesnt recognize that tax id and deems the claim out of network. there is no need to appeal, just simply call BCBS and advise your hosp was innw and why was this claim paid out of netwrk. it could also be possible the professional charges were truly out of net but the ins co will adjust it to be in-netwk if you notify them. claims adjusters or (the computer in EDI systems) are paying the claim according to how it is filed and it just needs adjusting when you contact them and bring to their attn.

Answer 6

These things can always be disputed. Get the medical records from the hospital showing that this was an emergency admission, and start calling Blue Cross until you get to someone in charge. In cases like this, the squeaky wheel gets the grease. Also, it might help to have your ob/gyn contact BCBS and plead your case for you. If you push hard enough, it will be covered.

Answer 7

this may be wrong but ill tell you anyway if it is a referral issue you can call you primary care doctor and ask him to give you a back dated ref. because BC referrals are on carbon paper they can be written up with different dates . or the doctor that work on your wife may not be in network with the insurance company you have it may just be a fluke in the ins companies system ...CALL THE INS COMPANY don't hang up till you get answers the INS reps can not hang up on you . they have to solve the problem it may take a while so be prepared to wait .I know cause I you to work on both ends of this type of situation. i was the billing clerk and an ins rep.

Answer 8

yeah, been there, done that. Someone pressed the wrong key, and the hospital came up as out network instead of in.

You'll have to call the customer service number on the back of your card on Monday, and get them to straighten it out. Happens all the time.

BE SURE to write down the name of the person you talk to.

Answer 9

I had Blue Cross Blue Shield health insurance for years and it is very good. Try to keep yourself away from UNITED HEALTH CARE insurance, I don't know if your are comparing policies, but please try to stay away from the insurance I mentioned

Answer 10

The EOB's probably not for the hospital. Its probably for a doctor she saw @ the hospital. And, they probably are out of network. Depending on the type of doctor, BCBS will probably adjust the claim as soon as you call them. They usually upgrade to pay out of network doc's claims, like they're in network. But, if they don't have a hospital claim to compare it to, it processed ot of the plan. They should fix it. Good luck