I've concluded from my experience that insurance companies design their procedures to deny first and ask questions later...it's in their interest to delay as long as possible making payments. It's absurd, of course, but I think you have to talk to insurance repr.s knowing that they are NOT there to help you solve problems...and you've got to keep poking them with different versions of the same question until they're forced to reveal the real problem. The most ridiculous one I had once was a claim was rejected because the billing code had an extra zero on the end of it and had 1 too many digits...a 5 year old would have recognized it as a typo but not the insurance company and all I got back was "not a covered expense.."
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Blue Cross is not covering our clinic visits?
- Thread starter westonsmom
- Start date
<div class="FTQUOTE"><begin quote><i>Originally posted by: <b>folione</b></i>
I've concluded from my experience that insurance companies design their procedures to deny first and ask questions later...it's in their interest to delay as long as possible making payments. It's absurd, of course, but I think you have to talk to insurance repr.s knowing that they are NOT there to help you solve problems...and you've got to keep poking them with different versions of the same question until they're forced to reveal the real problem. The most ridiculous one I had once was a claim was rejected because the billing code had an extra zero on the end of it and had 1 too many digits...a 5 year old would have recognized it as a typo but not the insurance company and all I got back was "not a covered expense.."</end quote></div>
Although I definitely agree they like to hold onto their $$ IF there is an error such as an incorrect billing code.....the insurance company can not be the one to change it. Even if its an "obvious" typo. Any alteration would be considered illegal. Its up to the provider of service to correct it once the insurance company rejects it. It is a royal pain in the butt tho!
I've concluded from my experience that insurance companies design their procedures to deny first and ask questions later...it's in their interest to delay as long as possible making payments. It's absurd, of course, but I think you have to talk to insurance repr.s knowing that they are NOT there to help you solve problems...and you've got to keep poking them with different versions of the same question until they're forced to reveal the real problem. The most ridiculous one I had once was a claim was rejected because the billing code had an extra zero on the end of it and had 1 too many digits...a 5 year old would have recognized it as a typo but not the insurance company and all I got back was "not a covered expense.."</end quote></div>
Although I definitely agree they like to hold onto their $$ IF there is an error such as an incorrect billing code.....the insurance company can not be the one to change it. Even if its an "obvious" typo. Any alteration would be considered illegal. Its up to the provider of service to correct it once the insurance company rejects it. It is a royal pain in the butt tho!
<div class="FTQUOTE"><begin quote><i>Originally posted by: <b>folione</b></i>
I've concluded from my experience that insurance companies design their procedures to deny first and ask questions later...it's in their interest to delay as long as possible making payments. It's absurd, of course, but I think you have to talk to insurance repr.s knowing that they are NOT there to help you solve problems...and you've got to keep poking them with different versions of the same question until they're forced to reveal the real problem. The most ridiculous one I had once was a claim was rejected because the billing code had an extra zero on the end of it and had 1 too many digits...a 5 year old would have recognized it as a typo but not the insurance company and all I got back was "not a covered expense.."</end quote></div>
Although I definitely agree they like to hold onto their $$ IF there is an error such as an incorrect billing code.....the insurance company can not be the one to change it. Even if its an "obvious" typo. Any alteration would be considered illegal. Its up to the provider of service to correct it once the insurance company rejects it. It is a royal pain in the butt tho!
I've concluded from my experience that insurance companies design their procedures to deny first and ask questions later...it's in their interest to delay as long as possible making payments. It's absurd, of course, but I think you have to talk to insurance repr.s knowing that they are NOT there to help you solve problems...and you've got to keep poking them with different versions of the same question until they're forced to reveal the real problem. The most ridiculous one I had once was a claim was rejected because the billing code had an extra zero on the end of it and had 1 too many digits...a 5 year old would have recognized it as a typo but not the insurance company and all I got back was "not a covered expense.."</end quote></div>
Although I definitely agree they like to hold onto their $$ IF there is an error such as an incorrect billing code.....the insurance company can not be the one to change it. Even if its an "obvious" typo. Any alteration would be considered illegal. Its up to the provider of service to correct it once the insurance company rejects it. It is a royal pain in the butt tho!
<div class="FTQUOTE"><begin quote><i>Originally posted by: <b>folione</b></i>
I've concluded from my experience that insurance companies design their procedures to deny first and ask questions later...it's in their interest to delay as long as possible making payments. It's absurd, of course, but I think you have to talk to insurance repr.s knowing that they are NOT there to help you solve problems...and you've got to keep poking them with different versions of the same question until they're forced to reveal the real problem. The most ridiculous one I had once was a claim was rejected because the billing code had an extra zero on the end of it and had 1 too many digits...a 5 year old would have recognized it as a typo but not the insurance company and all I got back was "not a covered expense.."</end quote></div>
Although I definitely agree they like to hold onto their $$ IF there is an error such as an incorrect billing code.....the insurance company can not be the one to change it. Even if its an "obvious" typo. Any alteration would be considered illegal. Its up to the provider of service to correct it once the insurance company rejects it. It is a royal pain in the butt tho!
I've concluded from my experience that insurance companies design their procedures to deny first and ask questions later...it's in their interest to delay as long as possible making payments. It's absurd, of course, but I think you have to talk to insurance repr.s knowing that they are NOT there to help you solve problems...and you've got to keep poking them with different versions of the same question until they're forced to reveal the real problem. The most ridiculous one I had once was a claim was rejected because the billing code had an extra zero on the end of it and had 1 too many digits...a 5 year old would have recognized it as a typo but not the insurance company and all I got back was "not a covered expense.."</end quote></div>
Although I definitely agree they like to hold onto their $$ IF there is an error such as an incorrect billing code.....the insurance company can not be the one to change it. Even if its an "obvious" typo. Any alteration would be considered illegal. Its up to the provider of service to correct it once the insurance company rejects it. It is a royal pain in the butt tho!
If you're out of network, I believe there's a referral process you can go thru. We had to do that when DS was born and had to be lifeflighted to a children's hospital with a high level NICU for his bowel obstruction surgery. The local surgeon was on vacation, but I still had to track people down -- believe the doctor on call had to send a form to our pediatrician, who sent to form onto medical administration, who made the call to refer us after the fact. We'd met our deductible, but certain things, such as his ambulance ride to the airport weren't covered. Took us several month to get this worked out -- after the fact.
Our current BCBS select choice covers out of network office calls, but only at 80% instead of 90%. Plus there are certain items they won't cover until we meet a higher deductible and even higher coinsurance amount. We choose to go out of network and at this point are unable to get a referral because our local clinic just became accreditted CFF facility. But we're not comfortable with going there and prefer going 250 miles away instead.
Our current BCBS select choice covers out of network office calls, but only at 80% instead of 90%. Plus there are certain items they won't cover until we meet a higher deductible and even higher coinsurance amount. We choose to go out of network and at this point are unable to get a referral because our local clinic just became accreditted CFF facility. But we're not comfortable with going there and prefer going 250 miles away instead.
If you're out of network, I believe there's a referral process you can go thru. We had to do that when DS was born and had to be lifeflighted to a children's hospital with a high level NICU for his bowel obstruction surgery. The local surgeon was on vacation, but I still had to track people down -- believe the doctor on call had to send a form to our pediatrician, who sent to form onto medical administration, who made the call to refer us after the fact. We'd met our deductible, but certain things, such as his ambulance ride to the airport weren't covered. Took us several month to get this worked out -- after the fact.
Our current BCBS select choice covers out of network office calls, but only at 80% instead of 90%. Plus there are certain items they won't cover until we meet a higher deductible and even higher coinsurance amount. We choose to go out of network and at this point are unable to get a referral because our local clinic just became accreditted CFF facility. But we're not comfortable with going there and prefer going 250 miles away instead.
Our current BCBS select choice covers out of network office calls, but only at 80% instead of 90%. Plus there are certain items they won't cover until we meet a higher deductible and even higher coinsurance amount. We choose to go out of network and at this point are unable to get a referral because our local clinic just became accreditted CFF facility. But we're not comfortable with going there and prefer going 250 miles away instead.
If you're out of network, I believe there's a referral process you can go thru. We had to do that when DS was born and had to be lifeflighted to a children's hospital with a high level NICU for his bowel obstruction surgery. The local surgeon was on vacation, but I still had to track people down -- believe the doctor on call had to send a form to our pediatrician, who sent to form onto medical administration, who made the call to refer us after the fact. We'd met our deductible, but certain things, such as his ambulance ride to the airport weren't covered. Took us several month to get this worked out -- after the fact.
Our current BCBS select choice covers out of network office calls, but only at 80% instead of 90%. Plus there are certain items they won't cover until we meet a higher deductible and even higher coinsurance amount. We choose to go out of network and at this point are unable to get a referral because our local clinic just became accreditted CFF facility. But we're not comfortable with going there and prefer going 250 miles away instead.
Our current BCBS select choice covers out of network office calls, but only at 80% instead of 90%. Plus there are certain items they won't cover until we meet a higher deductible and even higher coinsurance amount. We choose to go out of network and at this point are unable to get a referral because our local clinic just became accreditted CFF facility. But we're not comfortable with going there and prefer going 250 miles away instead.
I just wanted to add that BCBS has a rule that if there is no doctor who can care for your child (in this case, no accredited CF Center) within a 40 mile radius of your home, they HAVE to pay for the out of network doctor as though they were in network. I worked for BCBS for several years and that is their policy. If there is another CF Center closer that is in network, then they will not cover the out of network one.
That being said, there are many different types of policies. Some require referrals and some don't so that can make a difference in how it's covered too. Not knowing what type of policy you have, I can't give you any specifics.
One last thing. Even if there is no other dr in network, they will initially process your claim out of network. You have to call in and tell them that there is no other doctor who can care for your child in your area. They will verify that and then will reprocess the claim. But you have to initiate it. I know first hand how difficult insurance companies can be... I've been on both sides of it. There are good and bad reps anywhere and insurance is, by nature, a very confusing thing to understand. Unfortunately half the reps who work at insurance companies don't understand it.
Best of luck to you.
That being said, there are many different types of policies. Some require referrals and some don't so that can make a difference in how it's covered too. Not knowing what type of policy you have, I can't give you any specifics.
One last thing. Even if there is no other dr in network, they will initially process your claim out of network. You have to call in and tell them that there is no other doctor who can care for your child in your area. They will verify that and then will reprocess the claim. But you have to initiate it. I know first hand how difficult insurance companies can be... I've been on both sides of it. There are good and bad reps anywhere and insurance is, by nature, a very confusing thing to understand. Unfortunately half the reps who work at insurance companies don't understand it.
Best of luck to you.
I just wanted to add that BCBS has a rule that if there is no doctor who can care for your child (in this case, no accredited CF Center) within a 40 mile radius of your home, they HAVE to pay for the out of network doctor as though they were in network. I worked for BCBS for several years and that is their policy. If there is another CF Center closer that is in network, then they will not cover the out of network one.
That being said, there are many different types of policies. Some require referrals and some don't so that can make a difference in how it's covered too. Not knowing what type of policy you have, I can't give you any specifics.
One last thing. Even if there is no other dr in network, they will initially process your claim out of network. You have to call in and tell them that there is no other doctor who can care for your child in your area. They will verify that and then will reprocess the claim. But you have to initiate it. I know first hand how difficult insurance companies can be... I've been on both sides of it. There are good and bad reps anywhere and insurance is, by nature, a very confusing thing to understand. Unfortunately half the reps who work at insurance companies don't understand it.
Best of luck to you.
That being said, there are many different types of policies. Some require referrals and some don't so that can make a difference in how it's covered too. Not knowing what type of policy you have, I can't give you any specifics.
One last thing. Even if there is no other dr in network, they will initially process your claim out of network. You have to call in and tell them that there is no other doctor who can care for your child in your area. They will verify that and then will reprocess the claim. But you have to initiate it. I know first hand how difficult insurance companies can be... I've been on both sides of it. There are good and bad reps anywhere and insurance is, by nature, a very confusing thing to understand. Unfortunately half the reps who work at insurance companies don't understand it.
Best of luck to you.
I just wanted to add that BCBS has a rule that if there is no doctor who can care for your child (in this case, no accredited CF Center) within a 40 mile radius of your home, they HAVE to pay for the out of network doctor as though they were in network. I worked for BCBS for several years and that is their policy. If there is another CF Center closer that is in network, then they will not cover the out of network one.
That being said, there are many different types of policies. Some require referrals and some don't so that can make a difference in how it's covered too. Not knowing what type of policy you have, I can't give you any specifics.
One last thing. Even if there is no other dr in network, they will initially process your claim out of network. You have to call in and tell them that there is no other doctor who can care for your child in your area. They will verify that and then will reprocess the claim. But you have to initiate it. I know first hand how difficult insurance companies can be... I've been on both sides of it. There are good and bad reps anywhere and insurance is, by nature, a very confusing thing to understand. Unfortunately half the reps who work at insurance companies don't understand it.
Best of luck to you.
That being said, there are many different types of policies. Some require referrals and some don't so that can make a difference in how it's covered too. Not knowing what type of policy you have, I can't give you any specifics.
One last thing. Even if there is no other dr in network, they will initially process your claim out of network. You have to call in and tell them that there is no other doctor who can care for your child in your area. They will verify that and then will reprocess the claim. But you have to initiate it. I know first hand how difficult insurance companies can be... I've been on both sides of it. There are good and bad reps anywhere and insurance is, by nature, a very confusing thing to understand. Unfortunately half the reps who work at insurance companies don't understand it.
Best of luck to you.
Emily65Roses
New member
Problem with what Renee said... there <b>are</b> CF centers within a 40 mile radius. There are two in CT. Westonsmom just hasn't wanted to switch yet. <img src="i/expressions/face-icon-small-smile.gif" border="0">
Emily65Roses
New member
Problem with what Renee said... there <b>are</b> CF centers within a 40 mile radius. There are two in CT. Westonsmom just hasn't wanted to switch yet. <img src="i/expressions/face-icon-small-smile.gif" border="0">
Emily65Roses
New member
Problem with what Renee said... there <b>are</b> CF centers within a 40 mile radius. There are two in CT. Westonsmom just hasn't wanted to switch yet. <img src="i/expressions/face-icon-small-smile.gif" border="0">
Unfortunately in that case there isn't a whole lot you can do. If the other CF Centers are in network and you choose to go to one that is not, the insurance will say that's your responsibility. I would still fight it though. I would come up with some reasoning as to why you don't want to switch (and I'm sure you have your reasons)... You have every right to appeal and re-appeal. And I will tell you that there is an unwritten rule (kind of an inside secret) that very rarely will BCBS reject an appeal a 3rd time. If you have the time and patience to fight it (and at least a moderatly good reason), you can USUALLY win...it just takes time. Again, that's not written in stone...and I'm sure there are cases where they do deny a 3rd time... but not very often. They have been sued too many times and don't want to risk it if the customer has any logic in their case. Most people just won't take the time and effort it takes to fight it that long. I guess it depends on how much money is involved and if it's worth the fight.
Unfortunately in that case there isn't a whole lot you can do. If the other CF Centers are in network and you choose to go to one that is not, the insurance will say that's your responsibility. I would still fight it though. I would come up with some reasoning as to why you don't want to switch (and I'm sure you have your reasons)... You have every right to appeal and re-appeal. And I will tell you that there is an unwritten rule (kind of an inside secret) that very rarely will BCBS reject an appeal a 3rd time. If you have the time and patience to fight it (and at least a moderatly good reason), you can USUALLY win...it just takes time. Again, that's not written in stone...and I'm sure there are cases where they do deny a 3rd time... but not very often. They have been sued too many times and don't want to risk it if the customer has any logic in their case. Most people just won't take the time and effort it takes to fight it that long. I guess it depends on how much money is involved and if it's worth the fight.
Unfortunately in that case there isn't a whole lot you can do. If the other CF Centers are in network and you choose to go to one that is not, the insurance will say that's your responsibility. I would still fight it though. I would come up with some reasoning as to why you don't want to switch (and I'm sure you have your reasons)... You have every right to appeal and re-appeal. And I will tell you that there is an unwritten rule (kind of an inside secret) that very rarely will BCBS reject an appeal a 3rd time. If you have the time and patience to fight it (and at least a moderatly good reason), you can USUALLY win...it just takes time. Again, that's not written in stone...and I'm sure there are cases where they do deny a 3rd time... but not very often. They have been sued too many times and don't want to risk it if the customer has any logic in their case. Most people just won't take the time and effort it takes to fight it that long. I guess it depends on how much money is involved and if it's worth the fight.
blindhearted
New member
<div class="FTQUOTE"><begin quote> JazzysMom
Although I definitely agree they like to hold onto their $$ IF there is an error such as an incorrect billing code.....the insurance company can not be the one to change it. Even if its an "obvious" typo. Any alteration would be considered illegal. Its up to the provider of service to correct it once the insurance company rejects it. It is a royal pain in the butt tho!</end quote></div>
Being that part of my job is medical billing for a transport company, I can say that this is true. If the billing code is incorrect, we get a denial from insurance company and we, the provider of service, must resubmit with the correct code. And yes, it is a HUGE royal pain in the butt....even for the provider of service!
Although I definitely agree they like to hold onto their $$ IF there is an error such as an incorrect billing code.....the insurance company can not be the one to change it. Even if its an "obvious" typo. Any alteration would be considered illegal. Its up to the provider of service to correct it once the insurance company rejects it. It is a royal pain in the butt tho!</end quote></div>
Being that part of my job is medical billing for a transport company, I can say that this is true. If the billing code is incorrect, we get a denial from insurance company and we, the provider of service, must resubmit with the correct code. And yes, it is a HUGE royal pain in the butt....even for the provider of service!
blindhearted
New member
<div class="FTQUOTE"><begin quote> JazzysMom
Although I definitely agree they like to hold onto their $$ IF there is an error such as an incorrect billing code.....the insurance company can not be the one to change it. Even if its an "obvious" typo. Any alteration would be considered illegal. Its up to the provider of service to correct it once the insurance company rejects it. It is a royal pain in the butt tho!</end quote></div>
Being that part of my job is medical billing for a transport company, I can say that this is true. If the billing code is incorrect, we get a denial from insurance company and we, the provider of service, must resubmit with the correct code. And yes, it is a HUGE royal pain in the butt....even for the provider of service!
Although I definitely agree they like to hold onto their $$ IF there is an error such as an incorrect billing code.....the insurance company can not be the one to change it. Even if its an "obvious" typo. Any alteration would be considered illegal. Its up to the provider of service to correct it once the insurance company rejects it. It is a royal pain in the butt tho!</end quote></div>
Being that part of my job is medical billing for a transport company, I can say that this is true. If the billing code is incorrect, we get a denial from insurance company and we, the provider of service, must resubmit with the correct code. And yes, it is a HUGE royal pain in the butt....even for the provider of service!
blindhearted
New member
<div class="FTQUOTE"><begin quote> JazzysMom
Although I definitely agree they like to hold onto their $$ IF there is an error such as an incorrect billing code.....the insurance company can not be the one to change it. Even if its an "obvious" typo. Any alteration would be considered illegal. Its up to the provider of service to correct it once the insurance company rejects it. It is a royal pain in the butt tho!</end quote></div>
Being that part of my job is medical billing for a transport company, I can say that this is true. If the billing code is incorrect, we get a denial from insurance company and we, the provider of service, must resubmit with the correct code. And yes, it is a HUGE royal pain in the butt....even for the provider of service!
Although I definitely agree they like to hold onto their $$ IF there is an error such as an incorrect billing code.....the insurance company can not be the one to change it. Even if its an "obvious" typo. Any alteration would be considered illegal. Its up to the provider of service to correct it once the insurance company rejects it. It is a royal pain in the butt tho!</end quote></div>
Being that part of my job is medical billing for a transport company, I can say that this is true. If the billing code is incorrect, we get a denial from insurance company and we, the provider of service, must resubmit with the correct code. And yes, it is a HUGE royal pain in the butt....even for the provider of service!