Claim for Routine Check up denied by Blue Cross Blue Shield

I worked as a medical claims payer for 30 years and I can tell you
that when there were mistakes with claim payments resulting in
denials, it was mostly because the doctors' billing departments billed
incorrectly.

Now, I am not defending Blue Cross by any means. In working with them
I have found they were absolutely the most uncooperative and
unprofessional company around. So the point is, either or both your
doctor's billing department or Blue Cross could be at fault for your
claim problems.

I suggest you make an appointment with a Blue Cross representative and
find out exactly why they continue to turn down your claims. If they
won't meet with you, see if your town has any kind of insurance
advocate service that can read the fine print in your policy and make
sure it is being administered properly.

Also, talk to your doctor's office and make certain they are billing
Blue Cross correctly.

It's unfortunate but we all have to be pro-active when it comes to our
insurance coverage. There are so many different types of coverage,
extraordinary strict rules and misunderstandings of what is allowed
and what is not, it is difficult for the average consumer to figure it
all out.

Good luck to you and I hope you get your problem taken care of without
any more hassle.

Have you resubmitted your claims? BCBS is INFAMOUS For routinely
rejecting claims that have merit. They do this because X% of insureds
will just shrug and pay the bill. Resubmit your claim. Document
everything. When you resubmit your claim, photocopy the part of your
medical coverage booklet that says this visit should be covered and
include it with your bill.

BCBS is not the brightest blub in the pack when it comes to health
insurance. I have to have them through my work and are trying to be
patient but every time I turn around they are messing with my policy.
First I told them to change my coverage to a EPO. They do so and the
very same day take me out, then all of a sudden I'm back in again.
Then they start messing with my dental (Dominion Dental), first they
add me then they take me off. When I call the company they tell me
that I'm not on the EPO plan. But when my contact at my company calls
and they say I'm on the correct plan. I have received over 14 cards
in two months from the BCBS and Dominion Dental. It's crazy and
definitely not worth the money my company is paying them.
I'm really sorry to hear about your problems with them and wish you
the best of luck. If you figure them out please let us all know.

I wish I could be of some help.

This is just a shot in the dark - - but could this be an issue of the
'ol in-network vs. out-of-network coverage? Are you enrolled in an
EPO (Exclusive Provider) or HMO type of plan where you have to see
only doctors on their list in order to be covered - - and are required
to have authorization to see a specialist and/or any doctor that is
not in their network?

You state that you want to " . . . be assured that when I visit my
doctor my Insurance Provider will take care of me." Is "your doctor"
part of the Blue Cross/Blue Shield network?

With reference to the claim for your husband to see a specialist that
was denied for payment - - exactly what did the documentation denying
the claim give as the reason for non-payment?

Health insurance companies are getting very strict about what they
will and will not cover, but to have 14 unpaid claims tells me that
there is something very wrong here and that maybe it has to do with
the fact you are not utilizing in-network doctors. If this is the
case, then I would expect that Blue Cross/Blue Shield would explain to
you the terms of your plan so that you can received the coverage
you're entitled to.

Trying to be helpful - - Just a guess . . . . . .

Good luck. Maybe the denial was correct for some reason but I would
not be at all surprised if BC/BS made a mistake. I have my insurance
through BC/BS of Illinois and it makes mistakes all the time and is
not very good about fixing them.

This goes beyond BC/BS but I cannot understand why medical billing get
so fouled up. To be fair to the insurance companies, sometimes the
problem is the provider. I know it is complicated but so are a lot of
things. Like most people, I deal with a lot of bills for a lot of
things and the medical ones are the only ones I have to give more than
a cursory review before paying. I would be surprised if my medical
bills are right on the first pass even half the time.

There is one sure way to express your displeasure with BC/BS: Switch
to another health care provider when open enrollment time comes at
your husband's work.

Obviously, you still need to deal with the unpaid claims, and knowing
how they work, it's going to take some time before they finally get
their act straight and pay the claims. It might take you or him having
to return to the doctors office to ensure that there wasn't a billing
error there that caused the problem.

Is it possible that when the contract was renewed for this calendar
year, the yearly physical benefit was eliminated. That exact thing
happened to me. I'm covered under my husband's policy with his union
and in previous years, they covered physicals. I went for my annual
physical one time and everything, I mean everything, including the
blood work was not covered. When the union renewed the policy, they
got rid of that benefit in an effort to cut costs and have people get
their physicals from the union's medical department. Since most
people don't read their contract from year to year, they slipped that
one by most people.

I worked in health insurance with a major company for several years,
paying claims and answering claim questions.

It sounds to me, that because his doctor sent him to a specialist on
the suspicion that he had cancer, this was no longer coded ( or billed
as ) a routine physical.

A quick phone call to the doctor's office and a chat with the billing
specialist or office manager should be able to clear up what primary
diagnosis the claim bears. If it was indeed a routine physical, it
needs to be resubmitted to your insurer as such- but if he had
injections or any other procedures performed- you move out of the
realm of routine care.

I hope that helps a bit :)

I've dealt a lot with HMO'S and have had to read through pages and
pages of detailed paperwork...it's so confusing, especially for my
elderly parents, the whole system gets more and more complicated...
anyway I'd read over your packet to make sure these detailed claims
are covered. Some doctors belong to hospitals that have patient
advocates... I've found them a great source of information and found
that they do help as mediators and have gotten us favorable results...
so that may be something to look into in your area... I know here they
also work with BCBS of Pennsylvania...so i'm guessing the same holds
true in your area. Good Luck

Are you sure that a physical is included in your coverage, annually?
I also have BCBS of AL, and physicals are not covered for anyone over
the age of six. I think you might want to get your current policy and
look through it and double check.