Denied insurance claim, I need advice please.

[rydg187]

I had a major surgery on my right hand wrist for giant cell bone tumor, the surgery was en bloc wide incision w/ wrist fusion.

I was told by my surgeon before the surgery that Blue Cross had approved pre authorization for the surgery. My surgery was on 11-19-20. I was discharged from the hospital on 11-23-20.

Now 2 months after I have already had the surgery the claim is being denied.

Below is an email I just sent to my surgeon that explains clearly the problem I am having. I have not been getting much traction with my surgeons administration office, phone calls and emails have been unresponsive for the past 1-2 weeks. I need advice on how to proceed, I am uncertain what to do.

Hello xxxxxx,

I have called Blue Cross Blue Shield to check on the status of the $40,897.65 claim for inpatient surgery on 11-19-2020 thru 11-23-2020.

Pre authorization has already been approved for 11-20-20 thru 11-22-20. However authorization needs to be extended to include 11-19-2020 thru 11-23-2020. Two extra days. The 19th and the 23rd.

When the preauthorization was requested by Johns Hopkins the preauthorization was requested with incorrect dates of 11-20-2020 Thru 11-22-20

The correct dates in the preauthorization request should have been for the dates of 11-19-2020 thru 11-23-2020.

This is a very large amount of money. Please have your staff extend the preauthorization inpatient surgery. The phone number to call to have this done is 1-800-xxx-xxxx option 4.

My phone number is xxx-xxx-xxxx if you need to speak to me.

 

[leevena]

Sorry for situation. There is not nearly enough information provided to give you a definitive answer, but a few things come to mind. To begin with, it is your responsibility to make sure you have the pre-authorization for the procedure. The provider can start the process, but is your responsibility none-the-less.

It appears that the standard length of stay (los) for your procedure is 3 days, or the original length approved. I say that because the insurance company approved it. The question now becomes, why did you exceed that authorization time frame. What was the reason for the additional days?

It is possible that your surgeon does not believe you needed the extra 2 days and as such, is not trying to extend it for you. Normally in a situation such as this you would go back to the surgeon and have them adjust the los.

 

[rydg187]

My surgeon had assured me verbally all the pre auth was approved before the surgery even took place on 11-19-20. I asked several times, I did not know I would need pre auth for the 5 days of inpatient stay. I thought it was all bundled in with the pre auth approval for the surgery.

I have attached photos of my benefits booklet about pre auth. Per their provider agreement the provider is responsible for pre-authorization, not me.

My surgeon is an in-network provider. So per their provider agreement the provider is responsible for pre-authorization, not me.

I had my surgeon do a peer to peer review with Blue crosses medical director.

After the peer to peer review Blue cross sent me an approval letter saying "based on our peer to peer review of all the medical information provided at the time of review the in patient services are approved because it satisfies the criteria for establishing medical necessity." They approved the following dates.

11-20-20

11-21-20

11-22-20

I can't understand why on earth would my surgeon ...... knowing my surgery was on the 19th and knowing I would likely have a tough time walking and would be in extreme pain after having the bone graph taken from my hip. Knowing I would need at the very least a day in the hospital over night the very same day of my surgery on the 19th. But yet the surgeon only requested for pre auth for inpatient stay starting on the 20th.

After the surgery the hospital didn't know how fast I would recover. However It was certain I was going to be kept in the hospital all day on the 19th, they knew it before I even had the surgery.

On the 22nd the hospital staff should have requested additional pre auth for the 23rd. I was bed ridden and trying to recover from major surgery, Blue Cross can not seriously expect me to make phone calls to Blue cross while in the hospital on pain narcotics recovering from major surgery to seek pre auth. It should have been handled by hospital staff to requested additional pre auth for the 23rd.

How can Blue cross say the 3 days of inpatient stay 20,21,22 meet medical necessity, but the 19th and 23rd they refuse to pay simply because of a clerical error of failing to request pre auth on the 19th and hospital staffs failure to seek additional pre auth on the 23rd when I was bed ridden.

To top it all off Blue cross tells me the surgeon never requested pre auth for my in-patient stay until 12-21-2020 a month later. When they did request pre auth a month later it was approved for 20th,21st,22nd. But they never requested the 19th the day of my surgery or the 23rd.

Now Blue cross is trying to stick me with the $40,897 bill.

Seems to me I am not liable for this bill, the hospital failed to get pre auth for 5 days of inpatient stay only 3 days got approved, but per their provider agreement the provider is responsible for pre-authorization, not me.

What should I do? Do I wait and see if the hospital sends me a bill? Do I Appeal .... is that all I can do? Any help/advice is appreciated.

 

[fed up]

Have YOU called and spoken with anyone at BC? As to the length of stay, my Mom had each hip replaced and was kicked out after Day 3. The safest place to recover is AT HOME. Trading emails won't resolve this. You need a name and a conversation.

 

[sunny1ib]

Dear rydg,

I read your concern and the other parts of the thread. I have a few questions for you.

1. Have you received an Explanation of Benefits from your insurance company?
2. If so, have you contacted your provider's billing office?
3. If this claim has been processed, your Certificate of Coverage will advise you on how you can file an appeal. Perhaps there has been some issues surrounding the pre-authorization. If you had to stay extra days in the hospital beyond the preauthorized amount AND if it was ordered by a hospitalist or even your surgeon, there may be additional information that was not done by the hospital staff.

Mistakes like these happen. You are right, $40,000+ claim is not a bill that one needs to receive these days, especially during our extraordinary last 12 months. There are companies out there that can help you facilitate your claim for a fee.

I sure hope this information gives you some help and provide you with some guidance on what your next steps can be.

 

[leevena]

rydg187, you are confusing 2 separate issues, in the highlighted areas. The first one states that you are responsible for pre-authorization. The second highlighted area discusses who is financially responsible for the amount of claims not paid by the carrier. It states that if the provider is an in-network provider they will be responsible for the cost...unless you have agreed in writing to be responsible. Do you remember all the paperwork the providers had you sign up front? Guess what was in them...that you would be financially responsible.

You need to understand why you were in the facility an additional 2 days, and then appeal.