OT: Need Advice (Insurance Claim Denial ?)

[peewee.sixpack]

Need some advice if any of you have ever gone through a situation I am experiencing right now. I am going to keep this a brief as possible. This summer I had to place my teenage daughter into a long-term (90 day) rehab clinic for substance abuse/mental health. My wife and I worked with my insurance company (BC/BS) to find a facility that was in network. The closest facilities that we found that had beds available were in Tx. My out of pocket was $6k. Recently I received an EOB claiming the facility was out of network and we owe over $100K. We filed a dispute explaining the Tx BC/BS case manager actually set us up with this clinic and approved it.. BC/BS claims dept. said they would reevaluate and called back this week and said the facility was out of network. My wife called the Tx case manager and she is crawfishing saying she has nothing to do with claims. Currently after my wife provided the claims dept. with case managers information and emails they are going to look into the situation further. Here is the kicker, BC/BS actually paid the first couple weeks of rehab, so how in the heck can they claim the facility is now out of network for the remaining weeks?

So here are my questions:

1) Should I go ahead and engage an attorney or wait to see what BC/BS final determination will be? I have several attorney friends that have helped me in numerous situations but I have never had anything large like this.
2) Should I contact Mike Chaney's office (MS Ins. Commissioner) as if you google my situation you can tell I am not alone with these insurance practices

If anyone has been in this situation I would sure appreciate any help or advice.

Good news is my daughter is currently sober (~120 days) and is working hard to stay that (doing IOP, attending AA meetings, etc.) and I am proud of her efforts.

 

[Hugh's Burner Phone]

If you have friends that are attorneys and would do something initial pro bono or close to it then I would think it would never hurt to bring them in assuming they agree. I absolutely loathe insurance companies. They look for any reason to 17 you in the *** on a claim, but have no problem collecting those premiums every month. My apologies to any decent insurance people on this board, but damn.

Good news on your daughter. May her recovery be lasting.

 

[aTotal360]

This is over my paygrade but I'm praying for all of yall.

 

[johnson86-1]

Need some advice if any of you have ever gone through a situation I am experiencing right now. I am going to keep this a brief as possible. This summer I had to place my teenage daughter into a long-term (90 day) rehab clinic for substance abuse/mental health. My wife and I worked with my insurance company (BC/BS) to find a facility that was in network. The closest facilities that we found that had beds available were in Tx. My out of pocket was $6k. Recently I received an EOB claiming the facility was out of network and we owe over $100K. We filed a dispute explaining the Tx BC/BS case manager actually set us up with this clinic and approved it.. BC/BS claims dept. said they would reevaluate and called back this week and said the facility was out of network. My wife called the Tx case manager and she is crawfishing saying she has nothing to do with claims. Currently after my wife provided the claims dept. with case managers information and emails they are going to look into the situation further. Here is the kicker, BC/BS actually paid the first couple weeks of rehab, so how in the heck can they claim the facility is now out of network for the remaining weeks?

So here are my questions:

1) Should I go ahead and engage an attorney or wait to see what BC/BS final determination will be? I have several attorney friends that have helped me in numerous situations but I have never had anything large like this.
2) Should I contact Mike Chaney's office (MS Ins. Commissioner) as if you google my situation you can tell I am not alone with these insurance practices

If anyone has been in this situation I would sure appreciate any help or advice.

Good news is my daughter is currently sober (~120 days) and is working hard to stay that (doing IOP, attending AA meetings, etc.) and I am proud of her efforts.

Can't answer whether it's time to get an attorney involved. I suspect that once they see they can't brush you off they will eventually pay it, but if you have a friend that's an attorney, I'd ask them if it's time.

But as far as Out of network facilities, anytime I am getting something besides a routine doctors visit, I get on the insurance company's website, and screen cap the status of the provider as in network, and then email that screencap to myself. Do it when I schedule it and the day before or day of going to it. Not perfect because it doesn't get a time stamp from their website, but it does give something documenting contemporaneously that they were in the network when you checked.

I have yet to figure out how to handle getting an outpatient procedure and getting billed by the provider, anesthesiologist, hospital, and surgery center. Luckily only had to deal with that twice and basically just paid the provider and hospital bill and wore down the others telling them I only dealt with the hospital and the provider and to get one of them to bill insurance and me for it.

 

[peewee.sixpack]

If you have friends that are attorneys and would do something initial pro bono or close to it then I would think it would never hurt to bring them in assuming they agree. I absolutely loathe insurance companies. They look for any reason to 17 you in the *** on a claim, but have no problem collecting those premiums every month. My apologies to any decent insurance people on this board, but damn.

Good news on your daughter. May her recovery be lasting.

Problem is my friend has always done pro bono in the past is now an assistant DA. I shot him a message and anticipate him calling me tonight. My other friends are great guys they have a firm back home and that is who I will probably use if it comes down to it.

 

[horshack.sixpack]

Need some advice if any of you have ever gone through a situation I am experiencing right now. I am going to keep this a brief as possible. This summer I had to place my teenage daughter into a long-term (90 day) rehab clinic for substance abuse/mental health. My wife and I worked with my insurance company (BC/BS) to find a facility that was in network. The closest facilities that we found that had beds available were in Tx. My out of pocket was $6k. Recently I received an EOB claiming the facility was out of network and we owe over $100K. We filed a dispute explaining the Tx BC/BS case manager actually set us up with this clinic and approved it.. BC/BS claims dept. said they would reevaluate and called back this week and said the facility was out of network. My wife called the Tx case manager and she is crawfishing saying she has nothing to do with claims. Currently after my wife provided the claims dept. with case managers information and emails they are going to look into the situation further. Here is the kicker, BC/BS actually paid the first couple weeks of rehab, so how in the heck can they claim the facility is now out of network for the remaining weeks?

So here are my questions:

1) Should I go ahead and engage an attorney or wait to see what BC/BS final determination will be? I have several attorney friends that have helped me in numerous situations but I have never had anything large like this.
2) Should I contact Mike Chaney's office (MS Ins. Commissioner) as if you google my situation you can tell I am not alone with these insurance practices

If anyone has been in this situation I would sure appreciate any help or advice.

Good news is my daughter is currently sober (~120 days) and is working hard to stay that (doing IOP, attending AA meetings, etc.) and I am proud of her efforts.

Great news on your daughter! Encourage her to treat this rehab just like physical therapy. If it starts to hurt again, go see somebody and rehab it some more to work through the pain. The brain is just another organ that needs healthcare sometimes. I would get an attorney's advice on whether to start the legal process now or wait for final ruling, especially if you have a friend who will just take your call and give some basic advice.

ETA: with my first child, I had a dispute with BCBS, in MS, about whether she was a "pre-existing" condition as the timeline was very close to start of coverage but we did not know my wife was pregnant at the time. I spent many lunch hours sitting in the BCBS visitor area asking to speak to "the next person". Got it paid. No idea if my persistence mattered or not.

 

[Shmuley]

Need some advice if any of you have ever gone through a situation I am experiencing right now. I am going to keep this a brief as possible. This summer I had to place my teenage daughter into a long-term (90 day) rehab clinic for substance abuse/mental health. My wife and I worked with my insurance company (BC/BS) to find a facility that was in network. The closest facilities that we found that had beds available were in Tx. My out of pocket was $6k. Recently I received an EOB claiming the facility was out of network and we owe over $100K. We filed a dispute explaining the Tx BC/BS case manager actually set us up with this clinic and approved it.. BC/BS claims dept. said they would reevaluate and called back this week and said the facility was out of network. My wife called the Tx case manager and she is crawfishing saying she has nothing to do with claims. Currently after my wife provided the claims dept. with case managers information and emails they are going to look into the situation further. Here is the kicker, BC/BS actually paid the first couple weeks of rehab, so how in the heck can they claim the facility is now out of network for the remaining weeks?

So here are my questions:

1) Should I go ahead and engage an attorney or wait to see what BC/BS final determination will be? I have several attorney friends that have helped me in numerous situations but I have never had anything large like this.
2) Should I contact Mike Chaney's office (MS Ins. Commissioner) as if you google my situation you can tell I am not alone with these insurance practices

If anyone has been in this situation I would sure appreciate any help or advice.

Good news is my daughter is currently sober (~120 days) and is working hard to stay that (doing IOP, attending AA meetings, etc.) and I am proud of her efforts.

Go ahead and engage with Chaney's office and request that they investigate. Also, contact your Congressman's office (unless your Congressman is Bennie Thompson, and, if so, don't bother). Ask your Congressman's staff to make an inquiry with someone at Blue Cross/Blue Shield about your situation.

 

[Cantdoitsal]

Did you get it in writing from BC/BS that the out of pocket would be $6K and the TX Clinic was indeed in their network which would cover the rest? I hope you daughter gets well sir. God Bless on that. Unfortunately this is another example of how there is no true competition amongst service providers. $106K / 90 = $1177 per day. Also, have you spoken to the clinic in TX? They usually fight to get their money from the insurance companies.

 

[MagnoliaHunter]

I asked my brother. I won't say his name or what job he held, but he knows. He said to call the State Insurance Commissioner's office.

 

[Cantdoitsal]

I asked my brother. I won't say his name or what job he held, but he knows. He said to call the State Insurance Commissioner's office.

This. Forgot about THIS. VERY Good Suggestion. They LOVE to Nail Insurance Companies.

 

[horshack.sixpack]

Go ahead and engage with Chaney's office and request that they investigate. Also, contact your Congressman's office (unless your Congressman is Bennie Thompson, and, if so, don't bother). Ask your Congressman's staff to make an inquiry with someone at Blue Cross/Blue Shield about your situation.

I bet Bennie would like to stick it to Blue Cross.

 

[peewee.sixpack]

Did you get it in writing from BC/BS that the out of pocket would be $6K and the TX Clinic was indeed in their network which would cover the rest? I hope you daughter gets well sir. God Bless on that. Unfortunately this is another example of how there is no true competition amongst service providers. $106K / 90 = $1177 per day. Also, have you spoken to the clinic in TX? They usually fight to get their money from the insurance companies.

First thing I asked my wife as she is very detailed and a great note taker. She had saved emails from BC/BS but she said they were encrypted and will not show up now. I am pretty sure she does have other documentation. We will be contacting the facility asap. As far as contacting Mr. Chaney I mentioned that to my wife last night. I grew up with one of his daughters. He probably doesn't remember me but he was always really nice when I did meet him. I am in Benny's district and didn't figure that would be any help.

 

[horshack.sixpack]

First thing I asked my wife as she is very detailed and a great note taker. She had saved emails from BC/BS but she said they were encrypted and will not show up now. I am pretty sure she does have other documentation. We will be contacting the facility asap. As far as contacting Mr. Chaney I mentioned that to my wife last night. I grew up with one of his daughters. He probably doesn't remember me but he was always really nice when I did meet him. I am in Benny's district and didn't figure that would be any help.

I'm telling you Bennie would like to stick it to Blue Cross. Worst case, $500 campaign donation pales in comparison to $100k.***

 

[TNT.sixpack]

Don’t call your congressman. All they do is forward a letter to the Mississippi Insurance Department. I’ve got a question though – I assume you’re covered under a group health plan in Texas and that’s why you’re dealing with Blue Cross Blue Shield of Texas? Secondly, if it’s an employer sponsored plan are they self insured? Because if they are then no one‘s gonna be able to help you except for your employer. If you can answer those two questions, I can tell you what to do.

 

[squintdawg]

Need some advice if any of you have ever gone through a situation I am experiencing right now. I am going to keep this a brief as possible. This summer I had to place my teenage daughter into a long-term (90 day) rehab clinic for substance abuse/mental health. My wife and I worked with my insurance company (BC/BS) to find a facility that was in network. The closest facilities that we found that had beds available were in Tx. My out of pocket was $6k. Recently I received an EOB claiming the facility was out of network and we owe over $100K. We filed a dispute explaining the Tx BC/BS case manager actually set us up with this clinic and approved it.. BC/BS claims dept. said they would reevaluate and called back this week and said the facility was out of network. My wife called the Tx case manager and she is crawfishing saying she has nothing to do with claims. Currently after my wife provided the claims dept. with case managers information and emails they are going to look into the situation further. Here is the kicker, BC/BS actually paid the first couple weeks of rehab, so how in the heck can they claim the facility is now out of network for the remaining weeks?

So here are my questions:

1) Should I go ahead and engage an attorney or wait to see what BC/BS final determination will be? I have several attorney friends that have helped me in numerous situations but I have never had anything large like this.
2) Should I contact Mike Chaney's office (MS Ins. Commissioner) as if you google my situation you can tell I am not alone with these insurance practices

If anyone has been in this situation I would sure appreciate any help or advice.

Good news is my daughter is currently sober (~120 days) and is working hard to stay that (doing IOP, attending AA meetings, etc.) and I am proud of her efforts.

Hey - I work in healthcare and worked with BCBS of MS for years. I am in Charlotte now - so not connected there anymore. Anyway - my advice is to definitely get an attorney, even if you have to pay one a few grand to help navigate it. Get every documented communication you have organized from the beginning of the ordeal for that attorney. I see no way that the facility admitted your daughter without getting some form of prior authorization from BC/BS - so that has to be documented on their end. I would press them about that also. I suspect what happened someone at BCBS authorized it (maybe by mistake) and paid the first few weeks. Someone probably reviewed it due to the size of the claims and determined it was not supposed to be authorized. IMO - that is their issue to deal with and them paying proves that someone felt it was appropriate at some point. You acted in good faith and did what they said and tried to work through the system. Either BC needs to pay up, or the facility needs to eat some of the bill. The end result will probably be a combo of the two. If BCBS knows you mean business - they will act reasonable. I would also contact the facility and ask their participation in BCBS of TX to see if they are indeed in-network there. I would absolutely contact Mike Chaney's office and get advice or file some formal case on it. BCBS knowing you contacted them will not want any trouble and that will help with how they handle. Plus - Chaney is very reasonable and suspect his office will help out. Good luck!

 

[Dawgbite]

We ran into something similar but not nearly as extreme. Wife works for a company based in Ohio, live in Ms. For years we had great insurance through Aetna but a few years ago they changed to BCBS and I thought we would be fine, but it was BCBS of Ohio. Drs and hospitals in MS who showed that they were in Network turned out to latter deny charges because they were in network for BCBS of Ms, not Ohio. It was a cluster17 because they would Ok procedures, do the procedure, and then we would get an outrageous bill because it was out of network. Each BCBS in each state is separate from other states.

 

[Raiderdawg]

Need some advice if any of you have ever gone through a situation I am experiencing right now. I am going to keep this a brief as possible. This summer I had to place my teenage daughter into a long-term (90 day) rehab clinic for substance abuse/mental health. My wife and I worked with my insurance company (BC/BS) to find a facility that was in network. The closest facilities that we found that had beds available were in Tx. My out of pocket was $6k. Recently I received an EOB claiming the facility was out of network and we owe over $100K. We filed a dispute explaining the Tx BC/BS case manager actually set us up with this clinic and approved it.. BC/BS claims dept. said they would reevaluate and called back this week and said the facility was out of network. My wife called the Tx case manager and she is crawfishing saying she has nothing to do with claims. Currently after my wife provided the claims dept. with case managers information and emails they are going to look into the situation further. Here is the kicker, BC/BS actually paid the first couple weeks of rehab, so how in the heck can they claim the facility is now out of network for the remaining weeks?

So here are my questions:

1) Should I go ahead and engage an attorney or wait to see what BC/BS final determination will be? I have several attorney friends that have helped me in numerous situations but I have never had anything large like this.
2) Should I contact Mike Chaney's office (MS Ins. Commissioner) as if you google my situation you can tell I am not alone with these insurance practices

If anyone has been in this situation I would sure appreciate any help or advice.

Good news is my daughter is currently sober (~120 days) and is working hard to stay that (doing IOP, attending AA meetings, etc.) and I am proud of her efforts.

I have no idea if it’s a similar same situation, but BC/BS denied an in-network claim for my wife earlier this year that would have cost me $50,000+ Out of pocket. No warning until the denial letter showed up. Like you, they were were paying and then denied. We could not figure out what happened. BC/BS paid the physician and the beginning of her medical which started in Dec 2021. All in network. Then denied on new year’s.

After staying in the phone for almost 10 hours, I got someone that saw a note in our file: They said we did not send in the annual questionnaire regarding other insurance for 2022. Even though we completed the survey 5 months earlier in 2021, they said we were not confirmed for 2022. Strangely, they paid other claims in 2022, just not her major hospital charges. I finally got it straightened out, the day I received a direct bill from the hospital.

BC/BS couldn’t explain why only the large charges were denied in 2022 and not the others. BC/BS couldn’t explain why I had to re-acknowledge 5 months after I did in 2021. But something very silly almost turned into a big issue. Maybe it’s something very simple like that with your case.

Good luck.

 

[GTAdawg]

Need some advice if any of you have ever gone through a situation I am experiencing right now. I am going to keep this a brief as possible. This summer I had to place my teenage daughter into a long-term (90 day) rehab clinic for substance abuse/mental health. My wife and I worked with my insurance company (BC/BS) to find a facility that was in network. The closest facilities that we found that had beds available were in Tx. My out of pocket was $6k. Recently I received an EOB claiming the facility was out of network and we owe over $100K. We filed a dispute explaining the Tx BC/BS case manager actually set us up with this clinic and approved it.. BC/BS claims dept. said they would reevaluate and called back this week and said the facility was out of network. My wife called the Tx case manager and she is crawfishing saying she has nothing to do with claims. Currently after my wife provided the claims dept. with case managers information and emails they are going to look into the situation further. Here is the kicker, BC/BS actually paid the first couple weeks of rehab, so how in the heck can they claim the facility is now out of network for the remaining weeks?

So here are my questions:

1) Should I go ahead and engage an attorney or wait to see what BC/BS final determination will be? I have several attorney friends that have helped me in numerous situations but I have never had anything large like this.
2) Should I contact Mike Chaney's office (MS Ins. Commissioner) as if you google my situation you can tell I am not alone with these insurance practices

If anyone has been in this situation I would sure appreciate any help or advice.

Good news is my daughter is currently sober (~120 days) and is working hard to stay that (doing IOP, attending AA meetings, etc.) and I am proud of her efforts.

sorry to hear this. Insurance is a horrible crock. This past spring we had a hail storm come through our neighborhood. Every State Farm customer(including me) were denied damaged roof claims, while 95% of the non-state farm customers in the neighborhood got new roofs all through the Summer.

 

[Emma’s Dad]

One issue people are commonly confused about is getting treatment “pre-authorized” which is nothing more than confirming you are eligible and that the claim will be processed as per the terms of the plan. This is NOT a promise that the claim will be paid. The written plan terms (including network requirements and exclusions for out of network charges) typically govern whether the claim will be paid. So if you merely got your daughter’s treatment pre -authorized, that doesn’t mean they promised the claim will be paid. The plan terms determine payment.

Ironically, you have more leverage if you and your family (dependents, like your daughter) are covered under an individual plan as opposed to employer-provided group coverage. You can sue under state law for benefits and punitive damages for wrongful denial of benefits under an individual plan. The punitive damage exposure gets their attention. Employer-provided group plans, on the other hand, are governed by ERISA, a federal law that preempts (displaces) state law punitive damage and emotional distress (extra-contractual) claims.

Also, a claim that coverage was misrepresented by a group plan are nigh impossible to successfully litigate when the claim decision lines up with the documented plan provisions/exclusions (for example, excluding out of network charges) if the claim decision is in line with those written provisions—no matter what you were told. The plan, in defense, will just point to the documents and is entitled to rely on them. Claims governed by ERISA are therefore easier for the insurer to defend and present less exposure to the insurer.

So, I agree you should seek counsel and consider whether your claim is arises under an employer-provided group plan. If it does, then the plan documents govern and your claims are limited to those available under ERISA (basically, benefits and possibly attorney fees). If you have individual policy coverage, the insurer is exposed to the claim for benefits and also for punitive damages under state law for wrongful or “bad faith” denial of your claim or misrepresentation of your coverage.

I agree with those who say you should keep all communications and your insurance contract documents to determine if the policy or group plan terms were followed.

I would consult a lawyer in your home town who is knowledgeable about these issues.

 

[TaleofTwoDogs]

To answer your questions, "yes" for both.

As in all things legal, it comes down to the written word and in this case it's your group health policy. Know it well.
BCBS made a bureaucratic mistake and you are the default target of this mistake. Because they hold all the money they will definitely push the fault in your direction. You need to be proactive and do the things that will level the playing field. Get your ducks in a row including an attorney, the State Insurance Commission, a Consumer reporter (local TV stations or newspapers have these) and others that are friendly to your cause. Before jumping in with guns blazing, see if BCBS has come up with a solution that makes everybody happy. If not, because the money value of this claim is so large, I would recommend a meeting (if possible) with the BCBS rep from their customer service/claims dept. and bring your employer's rep with you to the meeting (make sure the employer is on your side). Be professional but remember the squeaky wheel gets the grease. After the meeting if things are still not resolved, bring in your other consultants. Sorry this happen to you.

 

[Podgy]

Need some advice if any of you have ever gone through a situation I am experiencing right now. I am going to keep this a brief as possible. This summer I had to place my teenage daughter into a long-term (90 day) rehab clinic for substance abuse/mental health. My wife and I worked with my insurance company (BC/BS) to find a facility that was in network. The closest facilities that we found that had beds available were in Tx. My out of pocket was $6k. Recently I received an EOB claiming the facility was out of network and we owe over $100K. We filed a dispute explaining the Tx BC/BS case manager actually set us up with this clinic and approved it.. BC/BS claims dept. said they would reevaluate and called back this week and said the facility was out of network. My wife called the Tx case manager and she is crawfishing saying she has nothing to do with claims. Currently after my wife provided the claims dept. with case managers information and emails they are going to look into the situation further. Here is the kicker, BC/BS actually paid the first couple weeks of rehab, so how in the heck can they claim the facility is now out of network for the remaining weeks?

So here are my questions:

1) Should I go ahead and engage an attorney or wait to see what BC/BS final determination will be? I have several attorney friends that have helped me in numerous situations but I have never had anything large like this.
2) Should I contact Mike Chaney's office (MS Ins. Commissioner) as if you google my situation you can tell I am not alone with these insurance practices

If anyone has been in this situation I would sure appreciate any help or advice.

Good news is my daughter is currently sober (~120 days) and is working hard to stay that (doing IOP, attending AA meetings, etc.) and I am proud of her efforts.

Great news about your daughter. I hope she and you find peace and happiness and all the joy life can bring. You've gone through enough. Get an attorney. Insurance companies screw over Americans repeatedly and our elected leaders allow it. I guess that means we allow it to, or just think we can't do anything about it, because we keep electing them.

 

[Old Fart Dawg]

Call Chaney’s office

 

[johnson86-1]

We ran into something similar but not nearly as extreme. Wife works for a company based in Ohio, live in Ms. For years we had great insurance through Aetna but a few years ago they changed to BCBS and I thought we would be fine, but it was BCBS of Ohio. Drs and hospitals in MS who showed that they were in Network turned out to latter deny charges because they were in network for BCBS of Ms, not Ohio. It was a cluster17 because they would Ok procedures, do the procedure, and then we would get an outrageous bill because it was out of network. Each BCBS in each state is separate from other states.

You really can't rely on the Doctors or Hospitals to tell you whether they are in network. I mean, I guess if you get it in writing, you can probably force them to accept in network payments (assuming your insurer will make them). But you need to go to your insurance company to determine who is in network and document it. Everyone insurance I have ever had has a website where you can look up in network providers.