Anthem BCBS - $10k lifetime max
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Most, if not all, of the bills are in: $66k for the hospital, $32k for surgeon's fee, $31k for assistant's fee, $3400 for anesthesia, and various lab and xray charges. I'm at almost $140k, before insurance.
I was a simple, no-complications revision: one night in the hospital, 4 hr operation.
All claims received for doctors and ancillary providers have been processed and paid, insurance paid out almost $5k.
The allowed amount for one night in the hospital was $9500, but insurance has denied the claim in full, and I'm responsible for the entire $66k (I know I can negotiate this down, but am not to that point yet). The reason they denied it, is that they say I've maxed out my $10k lifetime obesity treatment benefit.
I called Anthem, they said that all my presurgical appointments (consults, EGD, bone density, etc) are counted against the max, as well as $3k of claims in 2010. I can only guess that those are related to my lapband, but I'm not sure how. My last fill was in 2010, and that was only $250.
Before I had my sleeve, I called insurance to ask about the max (it's a new thing, implemented in 2010, did not exist in 2006 when I got my band). I was told only surgical services counted towards the max, not my consults and tests. Unfortunately, I didn't keep record of the date/time of the call. So I've made a request to have all my phone calls from 2012 pulled by insurance. And also have requested that they give me a full accounting of all claims applied to my max, so that I know what the heck they are looking at in 2010, and can articulate my appeal clearly.
I'm just so frustrated. Was expecting to pay my $2500 out of pocket max, plus $1000 surgery copay, plus a few thousand of the hospital portion overage. Now I'm potentially facing bankruptcy, because where the heck I'm going to get tens of thousands of dollars, I just don't know.
Has anyone else had a similar issue?