BCBS Illinois - Pre-certification $1,000 Penalty

[usmsci]

So my wife and I had a baby 3/6/2014, due date was 2/26/2014. Insurance with BCBS through employer started on 3/1/2014. I started with employer in January 2014 and got all the paperwork ahead of time for insurance and read through all of it.

I got my bill from the hospital and there was a $1,000 Penalty for not calling 2 business days after being admitted into the hospital. I am pissed. How can this really be legal?

1. Is it really reasonable to expect someone to remember after no sleep in the hospital and barely awake that they have to call the insurance company 2 business days after get 'pre-certified'? How would someone remember that they read this little stipulation months before? It sounds like a way to get peoples money.

2. "BCBS has established the MSA(Medical Services Advisory) for the specific purpose of assisting you in determining the course of treatment which will maximize your benefits provided under this Certificate. Should you fail to notify the MSA as required by the PreAdmission Review provision of this section you will then be responsible for the first $1,000 of the Hospital or facility charges... blah blah blah...". "Our records do not indicate a call was made to pre-certify the hospital stay..."

So i would like to know whats the purpose of getting certified by calling them so that they can 'determine the course of treatment' when we have already gone home from hospital??? What is the purpose of 'performing a review' of services including Maternity when they already cover maternity services and I have already been admitted, had the baby, stayed at the hospital and gone home??? Why would they need to pre-certify the hospital stay if Ive already gone home???

It sounds like they are fining me for simply not letting them "review" something that they already cover???

Can someone give me any advice as to what to do? Or if anyone has been through this type on nonsense??

 

[AllenChicago]

USMSCI,

Call BCBS-IL before 3pm CDT and ask to speak to a supervisor 1-800-538-8833. (Less busy before 3pm) Tell him/her that you want the $1,000 penalty waived, or you'll file a formal complaint with the IL dept of insurance.

I had a client where the BCBS website told her one thing, but the policy arrived different. BCBS didn't resolve her issue until the 4th call, when she threatened to file a formal complaint. Then, they fixed her issue in 3 days.

So cut to the chase and threaten a formal complaint right up front. They don't want the hassles of having to formally respond to your complaint. Good luck!

Allen

 

[usmsci]

USMSCI,

Call BCBS-IL before 3pm CDT and ask to speak to a supervisor 1-800-538-8833. (Less busy before 3pm) Tell him/her that you want the $1,000 penalty waived, or you'll file a formal complaint with the IL dept of insurance.

I had a client where the BCBS website told her one thing, but the policy arrived different. BCBS didn't resolve her issue until the 4th call, when she threatened to file a formal complaint. Then, they fixed her issue in 3 days.

So cut to the chase and threaten a formal complaint right up front. They don't want the hassles of having to formally respond to your complaint. Good luck!

Allen

Allen,
I already sent a letter of appeal and was denied based on their stipulation that you must contact them within 2 business days after admission (for maternity). So since i did not do that they wanted to penalize me $1,000. The part that i don't get is the reason that they want you call , i.e. for making sure everythign is fine and you get the correct treatment.. blah blah... none of that matters because we went home after the delivery in 2 days. Two business days after admission would have been 4 actual days.

So since my appeal was already denied.. what options do I have? This stipulation really almost sounds illegal. It seems that a case could be made that is unreasonable for someone to remember that you have to call within 2 business days atfer being admitted for maternity.

I would also like to note that on the original bill from the insurance company explaining the $1,000 charge it states, "Your Health Care plan requires an approval from your MSA advisor prior to an inpatient hospital admission. Since you elected to be admitted without this approval you are responsible for the first $1,000 of eligible charges. This amount is not applicable to your out-of-pocket expense maximum."

- So here it says "prior to inpatient hospital admission" but the health care booklet says two business days after admission. Maybe im just hoping that they messed up but i am not sure how to proceed.

They also mention at the end of the denial letter that I can take up this matter with the Illinois Dept of Insurance and they give me phone numbers...

Not that it matters - but I am not an Illinois resident.

Let me know what you think.. thanks..

 

[kgmom219]

1. Where are you located? If the company headquarters are in Illinois, you can have a BCBS policy, but in a different state. You need to find out where the policy is filed.
2. Once you find out what state the policy is filed in (I would ask HR), file a complaint with THAT department of insurance.
3. If its listed in the policy documents, that's what is called a "contractual denial". AKA...you are out of luck. But I would file the complaint anyway. You never know.

Hope this helps. And congrats on the new baby!

 

[usmsci]

1. Where are you located? If the company headquarters are in Illinois, you can have a BCBS policy, but in a different state. You need to find out where the policy is filed.
2. Once you find out what state the policy is filed in (I would ask HR), file a complaint with THAT department of insurance.
3. If its listed in the policy documents, that's what is called a "contractual denial". AKA...you are out of luck. But I would file the complaint anyway. You never know.

Hope this helps. And congrats on the new baby!

I am in Mississippi and my employer is located in Chicago so i would assume its filed in Illinois. I dont see any reason why not???

I just question the legality part of this clause based on a 'reasonable' test. Would you expect someone to reasonably remember months or years in the future that you need to call two business days after being admitted?? Especially after no sleep in the hospital for 2 days and your mind is on the new baby.

 

[kgmom219]

I am in Mississippi and my employer is located in Chicago so i would assume its filed in Illinois. I dont see any reason why not???

I just question the legality part of this clause based on a 'reasonable' test. Would you expect someone to reasonably remember months or years in the future that you need to call two business days after being admitted?? Especially after no sleep in the hospital for 2 days and your mind is on the new baby.

Each state has their own laws for insurance. If the policy is fully insured, it has to abide by MS law. Again, ask HR.

Yes, its legal. Reasonable? Maybe. But if its in the contract, that's the rule.

 

[usmsci]

Each state has their own laws for insurance. If the policy is fully insured, it has to abide by MS law. Again, ask HR.

Yes, its legal. Reasonable? Maybe. But if its in the contract, that's the rule.

I also question the legality based on the purpose of calling 2 business days after being admitted. If the purpose is to just 'know' that i have been admitted , well they;ll get the bill from the hospital. The purpose, as stated by them, however is that they want to be notified to pre-certify or review the hospital stay and to make sure the correct course of treatment is given. Problem is, after 2 business days we are already home. So i am not sure what the call after 2 business days actually solves. We were admitted on Thursday and left the hospital Saturday. Monday would have been 2 business days so determining the course of treatment, and reviewing the hospital stay seems irrelevant at that point...

Where in the MS law would i check regarding this?

 

[kgmom219]

I also question the legality based on the purpose of calling 2 business days after being admitted. If the purpose is to just 'know' that i have been admitted , well they;ll get the bill from the hospital. The purpose, as stated by them, however is that they want to be notified to pre-certify or review the hospital stay and to make sure the correct course of treatment is given. Problem is, after 2 business days we are already home. So i am not sure what the call after 2 business days actually solves. We were admitted on Thursday and left the hospital Saturday. Monday would have been 2 business days so determining the course of treatment, and reviewing the hospital stay seems irrelevant at that point...

Where in the MS law would i check regarding this?

I really am trying to helpful, but you aren't listening because you are not getting the answer you want to hear.

Call the Mississippi Department of Insurance. They have to approve contracts. See what they say. That's your only recourse.

I really hope it works out for you.