Health Insurance Claim Denial from Blue cross blue shield for premature child born in hospital?

Question

My daughter born in hospital was premature required to stay in the hospital for 20 days. Her claim of hospital stay denied saying that I did not call BCBS's medical management number in 48 hours. I did call number provided at back of the card same day my daughter born and they did not inform me about this medical management procedure. I am sure hospital must have also informed BCBS. My wife's claim during hospital stay are approved but my daughter's claim denied. Bill of my daughter's claim is more than 80,000$ out of that 74000 they paid and denied remaining. everytime I called them their representative told me that it's approved and shouldn't be a problem. but I recently got a letter that it's not approved. I did send grievance letter in writing but they did not approve. I am paying 700 $/month for so long time to BCBS. Do I have any chance to get this approved? if so, what procedure should I follow? please help.

one point is that my wife was admitted for emergency and all her claims are processed without any issues. my daughter born in hospital and I wasn't sure how long she is going to be there in hospital at the time.

Answer 1

Yes you do. You need to file a formal appeal. Most of the time, as long as it's medically necessary, and would have been approved if you had made the call, they will overturn the denial.

You should call the number on the back of your card, and ask them for the full details on exactly what you need to send to appeal the decision.

Answer 2

You should have a good chance to appeal this. BC/BS is generally reputable - see if you can contact someone more senior than who you are dealing with.

The other channel is the hospital's case management department. These people specialize in getting stays approved with insurance companies. Talk to the hospital's patient rep to get a meeting with case management so that they can provide the documentation, which they'll know a lot better than you.

The thing that really surprises me is that there's an outstanding after the insurance paid over $70K out of an $80K bill. Typically the hospital will bill about double they will accept as full payment from BC. BC has a fee schedule with the hospital which will pay a fixed amount and not what the hospital is asking for. The hospital is contractually obligated to accept this amount as full payment and "adjust off" the rest. Please check if this has been done.

Answer 3

First off, is your daughter offically added to your plan? Newborns are not automatically added to the health insurance - contrary to what many people believe. You have to fill out paperwork and submit a copy of her birth certificate and social security card thru your HR person. This could be a large part of your problem. (Also make sure she's effective from her actual date of birth - commonly insurances screw this up too!)

If that's all correct, then you do have a chance to get it reprocessed and approved. You didn't make your child be born premie, nor did you request her to be in the NICU for almost three weeks. Therefore, you've got a case for appeal. It will be frustrating and it will annoy you to no end, but insurances count on that - they figure if they p*ss you off enough, you'll pay.

Call member services at your plan and ask for the formal appeals process for hospital charges - including contact name and address. Send them a letter in writing detailing your issue, keeping a copy for your records. Send it with delivery confirmation (usually no extra cost) and call them to follow up three weeks after they get the letter to check status. It might also help if you can have your daughter's doctors write a letter as well detailing her medical needs at the time. Nag the cr*p outta the insurance until they give up!

Good luck!!!!

Answer 4

As the purchaser of your insurance plan, you are responsible for knowing the rules. An extended hospital stay will usually require a call to the medical management department. It sounds like BCBS realizes the stay was medically necessary but has applied a precertification penalty.
If they have denied your grievance letter, I don't think there is anything else you can do. The response to the grievance will tell you if you have any other recourse.

Answer 5

No, baby is NOT covered the first six weeks. There is ZERO time. You will have to apply for Medicaid for the baby - child welfare health insurance - in the hospital, the day he is born. Keep in mind, if anything is WRONG with baby, and he needs NICU care, or something; or all those immunizations and newborn testing they'll want to do to baby in the hospital, NONE of that is covered. Many "for profit" hospitals run a c-section rate of around 40% or higher, and c sections have higher complications for babies, so THAT can run up the bill, too. Potentially, in a hospital, you can walk out of there owing tens of thousands of dollars in medical bills, for stuff that COULD have been avoided. The way most hospitals work, you'll walk out of there owing thousands and thousands of dollars for baby's medical bills, if NOTHING IS WRONG. That's what hospitals do - intervene, which causes more problems; test, innoculate (even a brand new baby's immune system), and of course, hospitals are full of sick people, so it's much more likely baby will be exposed to something serious there. Consider your birth options very, very seriously. Homebirth with a midwife is safer, and cheaper, for both mother AND baby. And see if babydaddy is willing to add baby to his policy through his employer, as soon as baby is born. That would be very helpful to you.

Answer 6

You need to call the insurance commissioner. We had trouble with our insurance company at one time and the insurance commissioner fixed the problem right away. First of all you need to DOCUMENT everything. Every time you talk to anyone regarding this matter you need to record it in a notebook. Date it, state who you spoke with and what was said. This is extremly important. Without it it may be hard to fight the case. Ask your wife if she remembers the name of the lady she spoke with the day she called the insurance company. That would be helpful to know. The more evidence you have the better off you are.
And.....i work at a hospital and no hospitals want to get stuck with any bills. All insurance companies require notification of hospital stays. For emergencies it is usually requires that you notify them within 24 to 48 hours after admit. Hospitals already know this. I have found it to be a common practice for the hospital to notify regardless if you have called yourself or not. You should check with your hospital to see if they did this. If so, they will have it documented....

Answer 7

Call them. Ask for a supervisor. Why did they deny the $6000?

They're partially paying the claim. Unless they denied the service as 'not medically necessary' the hospital shouldn't be billing you. Are they billing you? If they are, Blue can get involved. If they're not billing you, don't worry. This is probably part of the hospital's contract adjustment. Most In Network hospital's are forbidden from billing you for authorization based denials.