Question:
After being approved my insurance changed mind
In March 2003, my doctory submitted papers for approval for WLS. On March 31, 2003, my insurance, BCBS of MN, approved the WLS due to medical necessity of health problems. On May 16, 2003, I had an open RYN, stayed in hospital until May 19. About a week later I had an infection (which I am still fighting) to set up in my wound. Yesterday, June 09, I received my EOB for the procedure of WLS (before I went into the hospital I received pre-admission authorization for WLS) and all the cost. Well my insurance said they did not approve this procedure and they would not pay for it, but I have all the letters of approval and pre-authorization for the procedure. Do they have the right to refuse to pay for my sugery. Any help and suggestions as to what I should do will be greatly appreciated. — Gene F. (posted on June 10, 2003)
June 10, 2003
Gene- Your problem seems a lot like mine; after pre-approval, I was
hounded by the insurance company demanding all sorts of additional
information so that they could evaluate my claim. Then, even after they
sent me the formal authorization letter, they claimed that they had only
authorized my hospitalization and not my surgery. The short answer is:
they are breaching their contract with you and with the medical care
providers and you have a host of legal rememdies to force them to pay. I
involved my wife's employer (I am insured through her) and they were
great.
You might want to consider filing a complaint with your state's insurance
commissioner if your insurance company won't honor their initial
pre-authorizations.
— SteveColarossi
June 10, 2003
Hi there =) It could be something as simple as the processor who worked
the claim didn't see the note in the system showing that it was
authorized... I work for an insurance company and this happens quite
frequently, unfortunately. I wouldn't start worrying yet, just call and
offer the copies of the letters that you have, I'm sure they'll see them
and adjust the claims appropriately. Good luck!! I hope it all works out
and it was just a mistake =)
— Kimberly J.
June 10, 2003
Unless a change of policy went into effect after your approval (which I
would think they would have to inform you of), you shouldn't have to worry.
You had to have been approved or your surgeon would never have scheduled
you. I would call them and have them look up the approval records.
— Carolyn M.
June 10, 2003
I work for an insurance company, and sometimes the authorizations I enter
don't cross over to the claims system for whatever reasons. (Good thing I
work here - I had the precert person check the claims system when I came
back to work - and MY authorization for surgery didn't "cross
over"! All of my claims would have rejected!) It's a pretty easy fix,
and Kimberly could be right. contact your customer service department and
see if they have record of the authorization and tell them what has
happened. They may be able to fix it for you. The claims people will just
have to rework everything but that's part of their job!
— koogy
June 10, 2003
DOCUMENT EVERYTHING! Call the Hospital and see if they have the initial
approval on file, get a copy of that if they do. Send copies of everything
regarding their preapproval back to them and ask why now are the changing
their minds. Explain to them that you feel you have a "BAD
FAITH" case against them should you choose to seek legal
representation (make sure you use the term BAD FAITH). Contact you states
Insurance Commissioner and explain it to them and ask the intervene on your
behalf (this will usually work and get the Insurance company to straighten
up and "fly right") If all else fails contact and attorney!
— Marilyn Kay J.
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