Health Insurance Questions

I received a call from my surgeon’s billing office informing me that I owed them a rather significant sum of money. I told her I was under the impression that BC-BS had paid the full amount and she said ‘They did but then they took it back so you’re responsible’ or words to that effect. She refused to explain how they ‘took it back’ but she did say “It happens all the time.” She denies that the doctor’s office returned it, by the way.

Question: How can an insurance company make a payment and then ‘take it back?’

Question: Has this happened to anyone on the SDMB?

Question: Do I have any recourse?

Have you contaced BCBS and asked them the specifics of it?

BCBS of Mississippi has a website. You can register and then look up the status of your claims. I wonder if yours does?

ETA: Yes.

From Blue Cross Blue Shield of Florida.

The insurance company (and I am just speculating here) might delete your amount from a subsequent claim, and instruct the medical office to squeeze it out of YOU.

I think this is reprehensible, btw. (if that is what happened)

I was covered by BC-BS under a policy owned by my ex-wife, who was a Federal Government employee who has since retired. She was the designated policy holder and therefore all communications from BC-BS were sent to her; if the communication concerned me, she simply threw it out and/or ignored it. I could never obtain information from BC-BS since I was not the policy holder. To make the situation worse, my ex is no longer covered by BC-BS and wouldn’t communicate with them on my behalf even if she wasn’t. I don’t know what I will do about the bill.
Thanks for responding.

Do you happen to know if an insurance company can actually, legally do this?

That’s a horrid situation Louis. Just when you think she can’t screw you over any more! Geez.

Next I would grill the people at the clinic, I guess.

It may be that the clinic had contacted BCBS before the surgery, and gotten an estimate of how much they would pay; then after the surgery, found out that the insurance company denied the charges.

The insurance company will use any loophole or excuse to deny a claim. I think the answer to your question is “yes, they can” but don’t hold me to that.

I have had limited sucess in getting medical bills reduced by offering to pay cash. Sometimes it’s as much as 50%. You could try that.

Yes they can, and yes it’s legal if they can justify that you were not eligible for benefits. It sounds like you were not.

  1. You usually cannot be covered under the same policy as an ex-spouse. Especially if the ex-spouse is covered through her employer. In the case that an ex-spouse is required to insure the other spouse, they generally must be on their own policy, separate from the employer group policy. To maintain the policy as if you were still married is one type and a common type of insurance fraud.

  2. The insurance company isn’t instructing the doctor to squeeze you for money. They are simply not paying on a claim for which they are not responsible (or at least this is how it is justified). If the doctor wants to get paid for services, you are the only person they can pursue.

Red, I figured you would know! :slight_smile:

You should be hearing none of this over the phone - this should all be in writing. Your insurance company should have sent you a letter if they denied a claim (and normally you should get a statement when they approve it detailing how much was charged vs how much was paid, etc).
Don’t pay anything until it all is in writing, you agree with the amount they believe you owe, and you have exhausted your appeals with the insurance company.

But first you have to find out what exactly is going on (a couple of possibilities)

  1. You went to an in-network doctor and the procedure was initially approved/paid, but after review it was found to be elective/dental/ otherwise not covered under your insurance plan
  2. You went to an out of network doctor, the procedure is approved/covered, but you owe whatever your Copay/Coinsurance % is, plus whatever amount is deemed above “reasonable and customary” charges. This would be what is known as “balance billing”
  3. The surgeon’s office is mistaken - wrong patient, trying to bill you for charges disallowed by your insurance when they are in network.
  4. Somebody is trying to scam you, possibly someone who has hacked into or otherwise comprimised your clinics records.
  5. I initially missed the one about your ex-wife - they deemed you ineligible to be covered and reversed all charges from the period they didn’t cover you.
    But if this is the case then #1 you should be getting bills from other Drs/etc, and #2, they should owe you a refund of premium paid for the period they consider you ineligible. (which may have gone to your wife and you may have to get from her, if she legally owes it to you via divorce decree, etc)

Also, LouisB. IANAL but HIPAA regulations allow you to request any information about your coverage, and any claims that were denied relating to medical services you encountered. You should be able to determine at least why the insurance company has denied the claim AND your dates of eligibilty for benefit. If the insurance company denies you access to any of this information, you should take it up to the your state’s Department of Insurance (DOI).

I had a similar thing with the dentist. Seems my employer didn’t pay the premium one month and the company paid, then discovered that the company didn’t pay that month, so they took back the money.

So I had to tell my boss, who was like, “Yeah I guess we forgot to.” And after about three months they paid it. But it was quite a mess, thank goodness it was only a small amount.

As far as recourse goes, BCBS has a claims appeal process, which may get you somewhere as long as you were actually eligible when the surgery happened AND the surgery was preapproved (if required).

  1. At the time I was treated by this surgeon, I was still covered by BC-BS as my divorce wasn’t final. She wasn’t my ex at the time.

  2. The person who called me from the billing service told me that BC-BS had payed the claim, but that they then “took it back.”

Doctors’ offices tend to bill you for something that insurance has already paid, or has said you’re not responsible for, way more often than should happen.

The insurance companies negotiate lower rates. So, the doctor charges $300 and the insurance company says it will pay $200 and the extra $100 is “rate reduction” that you’re not responsible for. And yet, the doctor’s office will send you the bill, showing $300 charge and $200 paid by insurance, and ask you for the other $100.

You should let the insurance company and the doctor figure it out. Don’t pay until/unless the insurance company says you should, and even then most insurance companies have a process whereby you can ask for a review of their ruling.