Need help to proceed with corporate appeal w/ BCBS of Minnesota

janiceg415 · August 2013

I have been battling with BCBS of Minn in getting them to reverse their denial on a less than 24 hr. recovery care stay following uni mastectomy with first step expander placement on Feb. 23, 2012. They based their denial on lack of medical necessity, even though both the oncology surgeon and plastic surgeon sent letters stating they felt it was common practice after this type of surgery and that it warranted a recovery care stay. Once again insurance denied.

Prior to surgery a call was made to insurance for a prior authorization of the scheduled procedure and that it would be done in an ambulatory surgery center instead of a hospital, and was told that I had a recovery care benefit. Never once did they state that any criteria needed to be met for this benefit.

Now 18 months later I am still struggling to get this paid. My provider's insurance dept. have made every effort to assist me, they stated they have never come across a situation such as this following a mastectomy & initial reconstruction.

I would appreciate any advice or thoughts on how to get this appeal reversed.

dltnhm · August 2013

So is the problem that you had this at an ambulatory surgical center rather than a hospital? Insurance prior authorizations are so important. It appears that the pre-authorization was accepted by the ambulatory surgical center. If everything was coded correctly, I would think the center and the insurance should figure this out.

Have heard of others having trouble however with not using an actual hospital.

Hope you can work this out.

janiceg415 · August 2013

I wasn't given a choice as to hospital or ambulatory surgery. Both doctors concurred that they felt it was best for me to stay in recovery care to monitor my vitals, manage pain control & watch for any complications following the uni-mx and initial phase of reconstruction. I was out within 24 hrs start to finish. BCBS of MN states that my recovery care was not warranted due to lack of medical necessity.

I don't have an extra $2300 to pay for this stay and object to their denial of coverage. I am looking for anyone who has had similar experience and what materials they offered in an appeal.

Chickadee · August 2013

Consider contacting your states insurance commission as well. They may have experience with this type of denial.

peggy_j · August 2013

Good suggestion to contact the insurance commission. Maybe your state has a government agency that acts are as health insurance consumer advocacy group. BTW, have you considered just not paying and asking the hospital to take a write-off? I know $2300 is a lot for an indivdual to pay, but compared to the total cost of BC Tx, this is a small amount and they can take the write-off as a business loss.

MmeJ · September 2013

Hi, janiceg415. I'm sorry you're still messing around with this a year and a half after your surgery. I hope you are doing well otherwise.

My first fifteen years in the working world were in employee benefits - I've been on the insurance company, claims administrator and employer (HR) sides. I am in Minnesota so know something about the regs. I would like to help you do some navigating if I can ... I have some questions for you, if you don't mind. You can send me a private message if you prefer.

Is your insurance individual or through your employer?

Is the surgery center part of a larger network? Have you talked with a patient advocate and/or finance person at the surgery center, or someone who represents the surgery center in the corporation (if part of a network)? Does the facility have a contract with BCBS (in other words, are they a preferred provider/in-network)?

It seems to me that the issue is between BCBS and the facility, and you are caught in the middle. The facility wants to get paid. They need to put forth some effort.

BCBS in Minnesota has been in the hot seat more than once over the years for not paying valid claims; there was a big to-do in the early 2000s about mental health claims and they had to overhaul their entire case management operation because of it.

ibcmets · September 2013

Janice,

Patient resources may have a few legal resources for you.

Legal issues:

cancer legal resource center (DRLC) www.disabilityrightslegalcenter.org

Legal Services Corp www.lsc.gov 202 295-1500

National coalition for cancer survivorship, www.canceradvocacy.org

Healthlaw.org www.healthlaw.org

*patient advocate foundation www.patientadvocate.org

800 532-5274

Terri

janiceg415 · September 2013

Mmej

My insurance plan is through my employer?

The amburlatory surgery center is part of Marsfield Clinic, which is widely known & large of our area. I have been working with a claim specialist in their insurance area, who has been very helpful in trying to navigate thru this.   Yes they area a preferred provider/in-network.

Yes the issue seems to be that Marshfield when calling for prior authorization asked about whether I had recovery care but was not told there was certain criteria for it to be considered medically necessary. The facility has been working fervenetly with this, and providing everything that it asks for, letters from both of my surgeons, a letter from myself. A general internist reviewed the 1st appeal & based the decision on lack of medical necessity to warrant recovery care of more than 6 hours but less than 24 hrs.  Yes, I am caught in the middle.

Once again we are trying to go forward with a corporate appeal, and don't know what more I can add when sending this in other than everything we have already sent. We were told that we can ask for a surgeon who specializes in breast cancer to review it. I guess it doesn't matter that most women undergoing mastectomy can usually expect to stay at least over night for monitoring, etc. , but in this case they don't agree. Any other data to add to my appeal would be helpful.

janiceg415 · September 2013

ibmets

thanks for the resources, I will need to make some contacts. I hope that something will surely help with this.

Need help to proceed with corporate appeal w/ BCBS of Minnesota

Comments

Categories