My wife and I were RV traveling in a remote area of Wyoming. We had a private health insurance policy with Blue Cross in NC. I experienced a medical emergency and visited a small clinic about 4pm Mountain time. Doctor wanted to run a diagnostic CAT scan after an X-ray was inconclusive. He called Blue Cross in NC to get approval and got a recording saying the office closed at 5 pm Eastern time and to call back the next day. In great pain I asked if he could do the scan then if I agreed to pay should the claim be denied. I signed the paperwork, the scan was done and the problem identified. I began treatment immediately.
Blue Cross denied the claim as medically unnecessary and for failing to get pre-approval. I paid the clinic bill for the scan when it arrived at home. I then wrote the CEO of Blue Cross NC requesting reimbursement. Fortunately the Wyoming clinic was in the BC network. I explained in my letter the clinic was in network and it was a legitimate medical emergency. The diagnostic procedure was recommended by the in-network physician after a less expensive diagnostic tool failed. It was Blue Cross that chose not to staff the approval line 24/7 so Blue Cross is to blame for pre-approval not being obtained. The doctor in Chicago Blue Cross contracted to review the claim was not present during an emergency, potentially life threatening situation, and therefore could not realistically assess the situation at the time or question the decisions made in the moment by qualified medical personnel on the scene. I stated I am not a physician and therefore had to rely on the expertise, skills and advice of the trained professionals at the clinic. I did not make any threats. I simply stated I had a contract with BC and expected his company to fulfill its obligation.
Two weeks letter I received a letter from the CEO stating my claim had been reevaluated. A check for the amount previously denied was enclosed.
My wife and I never bother with the customer service bureaucracy when dealing with large corporations. When we have a legitimate problem, we always call or write the CEO’s office and explain the issue logically. With the exception of dealing with one American brand automobile manufacturer we have always been satisfied with the outcome. Why waste time dealing with people who are not empowered to make decisions?
Yep - and providers are supposed to tell you whether or not a procedure has been approved/covered by your insurance - if they do the procedure “under the assumption” it will be covered w/o telling you, and the insurer declines coverage, you’re not supposed to owe anything. There are forms the providers can use to show you your options and have you decide whether to have the procedure and under what potential personal costs - takes 3 minutes.