When insurance won’t give a prior authorization

elise24601
elise24601 Member Posts: 155
edited January 2019 in Employment, Insurance, and Other Financial Issues

Is it just a gamble as to whether they will end up paying for something?

I’ve never encountered this before but BCBS is telling me that they can’t provide prior auth for a surgery, even though according to the codes from my doctor it’s covered.

Wondering if anyone has dealt with this or has any advice

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Comments

  • edwards750
    edwards750 Member Posts: 3,761
    edited January 2019

    We have BC/BS too. What reason are they giving for not giving a prior authorization? It’s a gamble depending on their reason. Some facilities won’t accept your insurance without it. They always verified my insurance before any procedure could be scheduled.

    Diane

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  • gb2115
    gb2115 Member Posts: 1,894
    edited January 2019

    What surgery are you trying to get prior authorization for?

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  • elise24601
    elise24601 Member Posts: 155
    edited January 2019

    A procedure to improve my lymphedema

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  • gb2115
    gb2115 Member Posts: 1,894
    edited January 2019

    They may consider that not medically necessary since it's probably considered elective. See if your doctor will do a doc to doc call (called a "peer to peer") with the insurance company. That could push it through maybe.

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  • BellasMomToo
    BellasMomToo Member Posts: 305
    edited January 2019

    Even if you get autho from BCBS, make sure to keep a copy of it. I have BCBS. In 2017 I was hospitalized for a abdominal infection and spent 5 days in the hospital. The Drs would only release me if I continued on IV antibiotics at home for another 9 days. So they got autho from BCBS for an in-home nurse visits and IV antibiotics. A few days after being home I received written autho from BCBS. The wording was weird and I wasn't exactly sure what was covered, but I didn't think much about it. A month later I started receiving EOBs from BCBS -- I was being penalized $500 for each bill (5 separate bills!) because they claimed I didn't have pre-authorization for the in-home care.

    I called BCBS, they researched my file, and claimed I didn't have pre-autho. I gave them the (case?) number that was on the autho that I received and they couldn't recognize that number. Finally after more digging, they found the authorization and acknowledge that all the penalties will be reversed. It took a few more phone calls to get ALL the penalities reversed.

    So even if you receive autho from BCBS, be sure to keep a copy of it because they may not be able to find it in their records!

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  • vlnrph
    vlnrph Member Posts: 1,632
    edited January 2019

    Everything written above rings true. However, even when you have a prior authorization in place, sometimes the company will refuse to pay. In my case, I filed a complaint with our state insurance commissioner's office who required them to act promptly and add a percentage to their payment as a penalty.

    The data on LE surgery is still somewhat sketchy. Unless you are getting frequent infections, they might count it as experimental. If they won't talk to your doctor, try to gather whatever scientific reports you can and submit them with a formal letter requesting approval.

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  • edwards750
    edwards750 Member Posts: 3,761
    edited January 2019

    Elise - idk if it’s the same procedure or not but a lady in our church group flew to Houston to have surgery done to improve her lymphedema. She is in constant pain too. She read an article in a magazine about this new procedure and called the doctors who perform the surgery.

    She has Medicare which approved the procedure. All she is responsible for is her hotel stay while she is there.

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  • edwards750
    edwards750 Member Posts: 3,761
    edited January 2019

    Also, I had prior authorization for my Oncotype test but BC/BS subsequently denied it. Genomic Labs who conducts the tests said they do that all the time and they weren’t worried. They had to appeal multiple times. The test was $5k at the time. My low score from the test allowed me to dodge chemo.

    Diane

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  • vlnrph
    vlnrph Member Posts: 1,632
    edited January 2019

    How ironic that Medicare would pay for a procedure but not the basic compression garments every LE patient needs! The technique I am most aware of is microsurgical anastomosis which requires highly specialized instruments and training - certainly not as cheap as simply wearing a sleeve and glove...

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  • edwards750
    edwards750 Member Posts: 3,761
    edited January 2019

    That makes zero sense for Medicare to do that. I have to admit I was surprised they were footing the bill.

    Diane


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