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Here is a letter I sent to Blue Cross Blue Shield asking for reconsideration of denial of payment of part of my heart procedure. I dont' have much confidence that it will be resolved. So even if you call to check your coverage with BCBS BEFORE receiving medical services, you can't count on the information you get.

I am sending this as an official request for reconsideration of the determination that I am responsible for 30% of certain medical supplies (stent) and prescription drugs for my angiogram and angioplasty procedures at Washington Hospital in Fremont, California from 2/24/2011 – 2/25/2011.

Blue Cross Blue Shield (BCBS) Federal Employee Plan (Fepblue) is my primary health insurance carrier. I am also covered by my wife's plan which was Health Net - Affinity Medical Group. When my cardiologist informed me I would need an angiogram and possibly an angioplasty with stent, I called Health Net - Affinity to determine if my cardiologist and the hospital he uses were in their approved network providers list. They were not but they were preferred providers in my primary plan (BCBS). I was faced with a decision to change my cardiologist and hospital unless my primary carrier (BCBS) would cover most of the costs of the procedures. It was reasonable and sensible for me to check this, especially because my wife and I are retired and on fixed incomes. So I called BCBS on 2/15/2011 and spoke to Melissa. I explained to her that my secondary insurance (Health Net, Affinity) would not cover any part of these procedures with my current cardiologist and hospital so I needed to determine what would be paid by BCBS. I explained that if BCBS did not cover most of the costs, then I would need to change my cardiologist and hospital. I was fully prepared to do that so that Health Net - Affinity would pick up any remaining cost as it did for a different surgery I had in December, 2009 at Stanford. I explained the procedures I was to have: angiogram first and based on those results possibly angioplasty with stent. I then asked about the 30% note in the BCBS Service Benefit Plan (Fepblue) booklet. Let me repeat, I specifically asked about the 30% notation. Melissa advised me that the 30% would not apply to anything, agents or drugs, as long as they were part of the procedure I was to have. We spoke about the required outpatient copayment of $75. I told her that my doctor informed me that if I had to have angioplasty with stent, that I would probably have to stay overnight. So I asked about inpatient costs and whether I had to have my wife call for preauthorization if that was determined to be the case after the angiogram procedure. She told me about the inpatient copayment of $150 a day and told me that I did not have to worry about preauthorization if the stay turned into inpatient, that the hospital would coordinate that with BCBS. I was thankful that I did not have to change my cardiologist or hospital facility. Melissa was very nice and very sympathetic, encouraging me many times not to worry about the coverage.

The procedure did turn into an overnight stay (more than 24 hours in the hospital) after the angiogram and then angioplasty with stent. On 3/21/2011 or 3/22/2011, I received an explanation of benefits from BCBS. It showed my obligation to pay $3,650.14 for "Medical Equip/Supply" and $57.25 for "Prescription Drug". You can imagine my shock at seeing this after my conversation with Melissa. When a person takes reasonable actions and precautions to determine insurance coverage and acts upon advice from a representative of the insurance company and then this happens, it is clear that BCBS has damaged me for this amount of money. I called BCBS and spoke to Christa on 3/22/11 and fully explained my situation exactly as I have described it here in this letter. After doing some research, Christa told me that the large amount was for the stent and when I told her I was told by Melissa that anything that was part of the approved procedure would not be subject to the 30%, she responded "…it is common that implants are billed separate from the procedure." I didn't know what that had to do with anything considering the fact that the stent is in fact an integral part of the angioplasty with stent procedure, otherwise the procedure would not exist at all. She also told me that the prescription drug charge to me was for an injectable prescription drug but that she was not totally sure why that differed from other drugs I was given that were not subject to the 30%. She said she would send that to a reviewer to make a determination. I asked her to be sure to include the other charge as well, for the stent, because none of this was consistent with the guidance and information I got before.

When I received a bill from Washington Hospital for $3,707.39, I called BCBS on 4/12/2011 and Sal took my call. Basically Sal could do nothing for me because the case was still open to Christa but said he would send Christa a message that I had called and a request to call me when there was information on my inquiry. Christa called me later that day and simply confirmed that all of the charges were correct based on the hospital coding the procedure as outpatient service. I again reiterated to Christa my experience that I had properly relied on information given to me before the procedure was done, by Melissa and that I have been wrongly damaged as a result. She said that there is a record of the call with Melissa and that she would ask a reviewer to review that record and if it is found that I was in fact not told that I would have to pay 30% of some of the charges in my procedures, then a determination would be made as to what to do about it. I then received a letter from BCBS on April 19, 2011 that stated "…after careful review it has been determined that the benefit was applied correctly and the benefit was quoted correctly during your phone call with our representative on 2/15/11." There was no explanation of how the benefit was applied correctly given the specifics of the conversation with that representative. The letter was three pages long but the entire response to my specific inquiry was only one sentence. The rest of the letter was a detailed description of my reconsideration and appeal rights and procedures.

The call record with Melissa will clearly substantiate what I have said in this letter. I have been damaged when I acted in a reasonable and responsible fashion on BCBS advice. If I was given correct information originally, I would not be writing this reconsideration request today because I would have secured a different cardiologist and hospital approved by BCBS and by Health - Net Affinity and the costs would have been covered after application of my secondary insurance.

I called the hospital billing department and received a temporary hold on the bill process until this is resolved, if resolved in a reasonable time. If this reconsideration is denied, I would like to have a full explanation of the reasons for the denial, specifically as it relates to the advice given to me by Melissa on 2/15/2011, especially regarding her statements that the 30% would not apply if the supply was a part of the angioplasty procedure. If BCBS considers the stent not to be a part of the angioplasty procedure, I would like an explanation of why that is the case. Also, I would like an explanation of why some parts of "medical equip/supply" were fully covered and another part (the stent) was not fully covered and why some parts of prescription drugs were fully covered but another one was not fully covered.

With regard to this procedure being identified as outpatient, I spoke at length with my cardiologist. He told me that his intent after the procedure was completed, was to have me admitted on an inpatient basis due to my other medical conditions (diabetes and hypertension) and that just because he or one of his office staff indicated on the billing that he was ordering observation for me, he told me he meant this to be observation during overnight impatient stay and that he is willing to clarify that for anyone in writing or otherwise. I was moved to a regular room with and monitored in the same way any other inpatient is monitored and cared for. He said that this matter was just a matter of terminology and that his or his staff's use of the word observation was unfortunately interpreted as outpatient service. He also advised me that this should be recognized by most in the medical field because this procedure is still done mostly on an inpatient basis especially when patients have history of other major medical conditions.

Review about: Blue Cross And Blue Shield Association Health Insurance.

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Anonymous
#533318

So true.I have breast cancer and scheduled a lumpectomy with interoperable radiation.

I called TWICE before the procedures, once to ask if I need prior approval and told "no" - the second time I asked if the interoperable radiation would be covered and was told "yes." I am now fighting $30 thousand dollars worth of radiation treatments they aren't covering--saying it wasn't medically necessary.I did all I was supposed to according to the brochure!

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