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Insurance Hell All insurance-related matters are here: Medicare, worker's compensation, appeals, denials, insights, wins, losses. PRICING is here too. Note: This forum has posts from 2006 forward. Older ones are in the Big File.


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  #1  
Old 05-23-2009, 11:26 AM
Lorraine Lorraine is offline
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Join Date: May 2009
Posts: 4
Default Anthem BCBS

Hello Everybody,
I had ADR surgery on May 4 for a ProDisc disc at C6C7. I thought the insurance was all settled but I got a statement Friday afternoon saying I had to pay $63,226.77. Of course, it is now Memorial Day weekend and all offices are closed so now I'll have to worry about this until Tuesday.

When I found out I needed surgery, my doctor filed for ADR but it was rejected at first. When I got the rejection because they deemed it "Medically Unneccessary", I didn't think it could be overturned.

My doctor, however, spent some time working on the appeal and actually got this ruling reversed. He explained it to me this way: only about 10% of people with cervical herniations need surgery, and 1 out of 10 of those 10% are candidates for ADR. He said I had the exact anatomy (remaining disc height, lack of arthritis, ...) as specified by ProDisc and would explain this in the appeal. Well, miracles of miracles, I got a letter from Athem saying that my "cerv artif diskectomy" had the Appeal Resolution of "Overturned". The letter also said "Upon review of all information presented, we have determined the services are medically necessary". At the bottom of the letter, they cc:'d The hospital (Largo Medical Center), me, and my doctor.

The surgery was then delayed a bit while I underwent allergy testing. The waiting was excrutiating, since I had this constant awful nerve pressure feeling going through my body, in addition to the tingling arms and legs, hands going numb, severe muscle spasms in my neck, and so on. Luckily it was found that I wasn't allergic to the metals in the disc and surgery was scheduled.

The Wednesday or Thursday before my surgery, I got a call at work from the incredibly nice surgery scheduler, L.L., from my doctor's office. She said, "Congratulations, your surgery was approved!" I said that I thought it was already approved. L.L. explained that the original approval was for a certain date which we missed due to my wanting to be tested for metal allergies. When she called the insurance, the representative was saying it was denied again. L.L. said she had spent a day fighting with them and getting the run around and being told she had to go to appeals. When she called the next day another representative said "Oh, we just have to change the dates".

At this point I got calls from the hospital, gave them my info, and was told to be there Monday at 5am and that I would have to pay 508$. I went through with the surgery and have been at home recovering.

Sooooo, Friday I get this statement that took me a while to decrpyt:

It looks like the Spine center my doctor is with charged 5,075 for the surgery, and Athem BCBS is paying them 3,289.99 for the negotiated price.

For the radiology, the charge was 30.00 and Athem BCBC is paying them 11.96 as the negotated rate.

But, for the hospital, the charge is $63,226.77 and this bill says that is also the "amount not allowed". They have this msg code 38 next to this which means "Services not provided or authorized by designated (network/primary care) providers". And, after saying "It is your responsibility to pay: $63,226.77", they say "thank you for using a Network Participating Provider".

Being the worrier that I am, I am going to worry about this over the 3 day weekend! I have the appeal paperwork where they said the surgery was medically necessary and the original denial was "Overturned". They even have a cc: of the hospital at the bottom. Their system must be really messed up!!!! I looked at attorneys in the yellow pages to to make myself feel better while I'm waiting for the business offices to be open.

:-( Lorraine
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Old 05-23-2009, 11:42 AM
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Harrison Harrison is offline
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Well Lorraine, firstly, congrats on achieving the milestone of getting your cervical spine repaired! On the insurance mess, nothing surprises me anymore with strange tales in the wild world of unmanaged care. I don't know how your situation will turn out; but if it were me...I wouldn't worry because of the WRITTEN approvals you have!


Try to relax and heal. Let it go a few days....or longer!
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Old 05-23-2009, 12:01 PM
Lorraine Lorraine is offline
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Thanks, Harrison, I will try not to worry so much. You are right, I need to focus on healing, this was a big surgery, after many months of pain and stress. ( Though, it did help to look at some of the attorney ads, some of these guys who do work in insurance claims look like mobsters and bill themselves as "aggressive". ) I'll just have to wait until Tuesday when offices are open again.
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Old 05-23-2009, 02:13 PM
jchebert1979 jchebert1979 is offline
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I agree with Harrison. Do not stress about this. You have documentation from them and that is all that matters. You may have to do a bunch of phone tag later, but I am pretty sure that you won't have to pay 60k.
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Chiari 1 malformation - successful surgery 1-22-09
C5-6 herniation (extrusion) with moderate central canal stenosis and bilateral foraminal stenosis.
Prodisc-C @ C5-6 5-28-09

Herniations/Buldges @ C4-5, C6-7, C7-T1, T1-2, T3-4, T6-7, T11-12
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