I dont even know if I am posting this in the right area. I need some serious advice. I recieved an explination of benefits from my Carefirst BlueChoice about a week ago stating that my cost of surgery was $6152.56. I was shocked today when I recieved another explination of benefits stating that I owe $1026.00 for anesthesia. Here is word for word of the explination of why it was not covered:

Under this members coverage, benefits for any services or supplies related to weight control, weight reduction or overweight conditions are excluded. Sicne it appears that these services relate to one or more of these exclusions, we are unable to provide benefits for these charges. Please refer to your employee benefit booklet.

WTH!! I called the insurance company to asked if they cover this procedure. I was told yes! In additon, I was given the guidlines ( 6mo supervised diet and documentation). I only had to do 3 months because I had documentation of 3 prior months of supervised diet. The lady that handles the insutrnace info also checked. I was approved 1 week after submitting my information.

So I called carefirst and the lady said she would look at my $1026 claim. After being on hold for about 10 mins she told me an adjustment was made and it would take 20 days. What does that mean. Am I going to recieve a bill for the whole 1026 plus the $6152.56? What should I do? How can they switch crap up like that?:smile:

Call your insurance company and tell them that you had a preauthorization for the surgery as medically necessary. You may need to send them a copy of it and ask them to reprocess the claims. I am sure your doctors office is on it too, but check that.

Keep chipping away at them. Call them everyday if you have to. Insurance carriers are more interested than ever in getting you to pay for stuff, even when it is covered to soften their payouts. They will let the hospitals keep billing you and sending late notices in the hope that you will just cough it up.

Don't let them get you.

-BSG

Whatever you do - DON'T PAY THAT $1026. You were pre- approved for this procedure by your insurance company and I'm sure your doctor checked on that. If not, your surgeon would not have gone ahead. Therefore, the costs related to this procedure are covered, too. Get copies of everything, starting with your insurance approval before your surgery. Make your insurance company send you everything they have relating to your surgery and GET THE NAME AND ID NUMBER OF EACH PERSON YOU TALK TO AND DOCUMENT ALL CONVERSATIONS - DATE, TIME, DEPARTMENT, ETC. And Good luck.

Today must be the day for insurance goof ups! I just got my hospital bill, expecting to see $250.00 due for my outpatient co-pay (that's all I was supposed to be responsible for), but instead I saw a balance of $2580.00. I freaked! Callled insurance company and I asked them to look into the claim and she said that for some reason, they charged me a $250.00 copay for each line on the claim! She said she submitted an adjustment and that it would take 30-45 days. Basically... an adjustment means that they will look into the claim and send the hospital/provider the adjusted amount. In my case, they will make an adjustment that will leave a $250.00 balance. If they approve your adjustment, your hospital should see another payment from insurance for the $1000 and you should only be responsible for the $6100...Good luck!

Rachel

Don't freak out too much yet...sometimes you get a copy of the bill that has been sent to insurance. I got a copy of the bill for my epidural when I had my daughter a couple of years ago and I panicked because it was for $1500. They aren't always marked very clearly that it is the bill that has been sent to insurance. Don't pay anything right now. If you owe them more than your co-pay wait until you receive another bill. But don't pay anything now!

Well I also have blue cross blue shield. My doctor was in the network last year, however he left the network this year. I do have out of network benefit, which means I am responsible for 20% and the insurance is responsible for 80%. My surgeon billed the insurance for $9,000 (I know this is crazy, but they always try to bill for a huge amount as insurance always cuts it down). In the beginning the insurance allowed around $2,000. Then all of sudden, I got the EOB that the insurance said that because they have not received the medical records (not sure what exactly they are), they are not allowing any amount to be paid. For now, I am responsible for all $9K. This is absolutely absurd. I called them twice before the surgery to make sure that they cover it. They said that it is okay to proceed and I don't need a pre-authorization since it is an out-patient surgery. This is also the answer that the surgeon's office got. The office has also submitted all the necessary documents and medical records to them. Now the insurance said that they don't have any record of that. Anyway, I am going to call my surgeon's office again and ask them to submit whatever medical records the insurance required from them. I just hope this issue gets resolved soon.

I thought I was the only one in Insurance Hell! I was given an authorization number for my surgery in December and have since been receiving bills because Humana has denied the claim. Humana states that weight loss surgery was not a covered expense even though there was an obesity rider and they authorized it. After about 20 very long calls to everyone at Humana (customer service, managers, appeals department, etc.) I went to the HR department at my husbands work and explained the situation to them. They got the Humana agent for his company (he works for a City) involved and I have had several conversations with her. I even stated that I would get an attorney if needed, but I was not paying. Through all this, I had the hospital collections department and my surgeons office calling for payment. Bottom line the claim is being paid and the reason it was denied is because they changed systems and the riders did not carry over on the policies??????? A bunch of crap as far as I am concerned - I think they just deny the claims hoping people will give up and pay so they don't have to!!

DO NOT give up. Keep fighting and get as many people as you can involved. Speak with the agent in charge of your policy and make sure that you document and have copies of everything!! I was also told not to pay a dime because then you were admitting that you were responsible for the payment. (I'm not sure it that is true but I wasn't taking any chances in having to pay a $14,000 bill!!).

Good luck and let us know how it works out.

I was just complaining today about my $2,200 bill. Thank you GOD that I havent had any mistakes. The only odd thing is that I paid a "copay" of $400 direct to the surgeon that was never submited to the insurance company. I have not received a bill yet, but my insurancce said they denied my preop blood work...come on how is that not related to the surgery?!?

I too, would not pay ANYTHING until you are fully satisfied with the outcome of your bill.

My surgeon billed the insurance for $9,000 (I know this is crazy, but they always try to bill for a huge amount as insurance always cuts it down

I don't think that is crazy. My billed amount was over $18,500. I think they paid $18,000.