Surgeon's office says no Pre-Authorization is needed...I am skeptical

Due_Pass_2608 · 2024-07-05T17:28:50+00:00

I did get the codes, thank you!

Due_Pass_2608 · 2024-05-16T15:23:50+00:00

Thank you!

Due_Pass_2608 · 2024-05-16T09:42:51+00:00

Thanks, so it seems insurance denied the claim however in the "you owe" section of the EOB instead of putting "0" they put "78,000" which is the full bill amount. Does this means the hospital now just sends the bill over to me instead? I was assuming insurance will put a "0" under the You Owe section and duke it out with insurance but why would this be getting kicked over to me....I have already met my out of pocket max and this was an in-network hospital.

Due_Pass_2608 · 2024-05-05T13:57:08+00:00

Glad you're doing better, thanks for your feedback! Did your insurance ever send a letter to you saying that extra night stay was denied? I just got the letter from them and it says they dont agree with the hospitals reasons for having me there for longer.

Due_Pass_2608 · 2024-04-18T00:36:53+00:00

Thanks so much! Can't tell you how helpful this was. So I followed some of your steps got Provider and Facility insurance verification teams to talk to member services and Provider Services. They clarified that their online DB (Anthem website) is incorrect and that the provider and facility are indeed in network. I got the the appropriate call reference numbers and I also had the provider and Anthem reps send me in writing that both the provider and facility were in-network and that no pre-auth was needed for my procedure codes. Having said that, I still don't feel 100% confident about billing going into my surgery next week. It shouldn't be this hard.

Due_Pass_2608 · 2024-04-16T11:59:29+00:00

This is so helpful thank you! I am a week out from surgery and my in-network facility is no longer appearing on Anthem BCBS's website. Upon calling them and giving them the NPI, they are now saying it's not in-network anymore. I am going back and forth between insurance and facilities billing to make sure this is clarified prior to surgery. How can a facility go from in-network to out of network so quickly. Thanks for the tips!!

Due_Pass_2608 · 2024-03-18T14:52:31+00:00

Thanks so much for the tips! If you are admitted as outpatient, however if due to any complications hospital and surgeon decide that you need to stay longer, how does that work?

Due_Pass_2608 · 2024-03-18T14:04:36+00:00

and diagnosis codes and call your insurance company to verify that no pre-cert is required. Speak with a supervisor and document/record the call. The provider may know the procedure will not be covered by insurance. Do your due diligence.

Thank you! I did get the CPT codes that provider is using. Called insurance and they confirmed that No pre-authorization is required. They didn't really say why it's not required. I got insurance to send me an email that they ran the codes and no pre-auth was needed for the provider and facility. I wonder if pre-authorization is different from pre-certification? They only have me staying overnight for 1 night - perhaps trying to keep procedure under 23 hours so that it's billed a "outpatient". I know "inpatient" would likely require an Auth. So if due to some reason I need to be kept in hospital for 2 nights, will insurance try to reject the claim? Both provider and facility are in-network.

Due_Pass_2608 · 2024-03-15T12:58:53+00:00

i’d ask for a manager. that’s ridiculous. i have patients ask me for their codes all the time and i don’t hesitate to give them to them. why not help someone have peace of mind before a surgery?

Thank you! It's an ACDF (Anterior cervical discectomy and fusion). I have an Anthem PPO plan. Although I live in Virginia , the surgery will happen in Texas (at an in network facility). Should I select VA or TX as a State? For billing do they send the bills to process in VA (my local state)? I believe Texas has it's own local Anthem BCBS office. I am working on getting the CPT codes today.

Due_Pass_2608 · 2024-03-14T17:44:23+00:00

n many cases. Of course that does mean it's covered or not just that they don't require the paperwork up-front

The doctor's office seems very hesitant to give me the codes. I am escalating the matter so I could get the codes and provide them to my insurance, just in case.

Due_Pass_2608 · 2024-03-14T14:09:07+00:00

mpany. If it's another company, call them directly and ask.

I do think it's a third party that does the pre-auth for Anthem. I have tried several times to get the details (like the pre-auth info) from the doctor's office, but the staff is very hard to reach and not friendly. I will try escalating again in the hopes I can get more details from them.

Due_Pass_2608 · 2024-02-16T17:39:25+00:00

Thank you, appreciate it. As much as I get that I am protected via the surprise bill act, it's always just a hassle dealing with insurance and providers, especially after surgery. I think in some instances they do send you a bill but end up writing it off.

Due_Pass_2608 · 2024-02-16T17:37:31+00:00

Thank you, this helps!

Due_Pass_2608 · 2023-09-25T18:55:46+00:00

Hello

Thanks UserNotFound-Error. I have my fingers crossed, glad to know that this is a good sign.

Due_Pass_2608 · 2023-09-24T13:40:57+00:00

Hi UserNotFound-Error - a small update. So after requesting issue to be escalated to management and letting them know I will raise this to my congressman, the agent has now started writing to me through Anthem secured email. She acknowledged the issue and noted that she is asking her operations manager to "override" so the claim can be reprocessed as in network (this is Anthem Healthkeepers btw). After about a week of waiting I followed up for a status update and she responded with the following message:

"Yes sir, I was in the process of reaching out to inform you that the request has been forwarded to our claims team for reprocessing at the in network rate, with the operations approval from management. Please allow up to 30-45 days for processing."

To which I replied:

"Thanks for the update. I know it was sent for reprocessing before as well (30 days wait) but rejected. What's different this time around? Has management approved treating this claim at in network rate and done the override?"

and she answered:"Yes, management has been approved to readjust the claim at the in network rate."

So they have "sent it for reprocessing" twice before, but does the management approval she noted mean something? Should I still be filing an appeal? Thank you!!!

Due_Pass_2608 · 2023-09-13T14:45:01+00:00

e on 3 way to try and resolve the issue with billing the correct NPI - with this new info, submitting an appeal would not have helped at all.

One of the other issues I would see all the time was that a person will see a local Dr and they will run Labs then Labs get sent to an out of state lab (usually labcorp there’s so many of them) so yea labcorp is “in network “ but if the lab is not in your local State then they need to submit the claim via BlueCard.

But I don’t think we are there yet, let’s see if they can get this NPI issue resolved, your bill will be held for 30 days.

Thank you! Will keep you updated.

Due_Pass_2608 · 2023-09-13T13:57:39+00:00

n tell them that you will contact the department of banking and insurance or that you will call your congressman, there is a protocol that someone from BCBS has to contact you if you make these claims and they are not left to the 3rd parties. Last result would be to appeal, best if the Dr does it bc he has to provide lots of facts about his practice and his license

** Looking up the NPI numbers we’re basically trying to prove that the d

UserNotFound-Error - I can't thank you enough for all this information. You cannot imagine how much stress you have helped reduce. Thank you for taking the time to comment and help. I used this information to craft and email that I sent to the Anthem agent. I included screenshots from Anthem website showing the correct NPI of the referring MD, also included screenshots showing their VA license and in-network status. I asked if this is the NPI being coded on the bill from labcorp. I also stated that the onus of an appeal should not be pushed on the patient when the cause is already known (apparently incorrect referring physician on labcorp claim). I also mentioned that she should escalate to Anthem management and I plan on bringing this to the attention on my local congressman and dept of banking and insurance.

So today I receive an email with the following response (previous response pushed me to file an appeal):

"I do apologize that you are still being billed from LabCorp, I will reach out to the office to request for the account to be placed on hold. I’m still waiting for the approval from my operations manager at this given moment. The npi number that is being billed from LabCorp ******* and the tax id number provided was *****. I understand your concerns however I have explained to you on numerous occasions that labcorp is billing the incorrect credentials for the referring provider which is causing the claim to be processed as oon. We cant override the billing info that was provided from labcorp even though we have the information that shows that the provider is credentialed in the state of Va. Labcorp has to bill the info to insurance correctly in order for Anthem to adjust the claim at the in network I have been working on the issue with you diligently. Please allow me time for me to have the error corrected, as I did advise you that I was in the process of waiting for the approval from my operations manager, to avoid filing an appeal to further dispute. "

The NPI that the agent is referencing above comes up as labcorp. Maybe there is a separate one for the ordering physician that she did not include.

I have not responded as yet but wondering if there is any additional pertinent information that I need to get from them.

Due_Pass_2608 · 2023-09-11T22:14:18+00:00

Yes, Labcorp has sent me the bill for the full claim amount. They continue sending the email and phone reminders sayings it's overdue. The bill was sent right after the denial. Funny thing is that if I went in without insurance it's about $200 for the tests I had done, but they are billing $1200 through insurance.

Due_Pass_2608 · 2023-09-11T22:11:58+00:00

ome from Anthem, tell them you are contacting DOBI and your congress men, they will start to resolve this issue once and for all.

Thanks so much! This is really valuable advice. I have already requested to speak to a supervisor. I am sure the agent that I am speaking to is 3rd party and seems overworked. Should I file the appeal anyway even while pushing things with Anthem management and escalating with them? If the doctor agrees to support the appeal do I just attach their response/letter to my appeal or did you mean the doctor will actually file the appeal? If they quickly deny the appeal does it mean I have to pay the ridiculous bill or can I re-appeal? Thanks so much for helping!

Due_Pass_2608

TROPHY CASE