Has anyone appealed reasonable and customary charges and won?

[buffalobillsfan]

Is anything ever easy???!!! It's been one thing after another.

I have Blue Cross/Blue Shield of Illinois even though we live in California. I went to one hospital for ER services and found out I had a bowel obstruction. I wanted to go to the hospital where my surgeon, Dr Rabkin, was working in San Fran. The hospital transferred me via ambulance.

My bill was for non-emergency (the ambulance company codes it non-emergency for any call not originated by 911) and mileage for $4000 for the 41 mile trip. Originally my insurance paid $832 and my portion was going to be $3200. F*&% YOU insurance company. Naturally I appealed. 16 pages of showing how critical a SBO can be, why my surgeon was the best person to perform it, why I couldn't drive myself, etc. They paid $1200 more and now my bill is almost $2000. Still not good enough for me.

They actually said they denied my appeal and that they overpaid my claim but would not be seeking a refund from me!!! They said that it was a non-participating provider and they paid reasonable and customary charges. I can file a 2nd level appeal and then the next step (they are a self-funded plan) is to go to the state. I don't want to make any errors in this and just get it paid for in full this time.

Has anyone appealed this type of charge and won? Any suggestions? I guess I should start by asking BCBSIL for documentation on how they calculated my payments. Did they go based on Medicare or what they pay participating providers? I am a reasonable person and accept what I think is fair. To me this is ridiculous. $2000 for a 41 mile ride?!!! I would have taken a scenic helicopter ride with my 10 of my closest friends for that price. Thanks in advance for any advice.

Cathy

 

[Spiky Bugger]

Who picked the ambulance company?

 

[DianaCox]

"I can file a 2nd level appeal and then the next step (they are a self-funded plan) is to go to the state." One of those two statements is, by necessity, wrong. Self-funded plans are not covered by the state (either the DMHC - which your plan is not in any case, because it is BCBSIL and not Anthem or BS of CA, or its equivalent in IL).

Your route of appeal is on the denial you received, and/or in the detailed description of your Evidence of Coverage document - which you need to obtain from your employer. And you should have the right to demand an accounting of where they get their "UCR" determination, including from which state.

 

[buffalobillsfan]

Who picked the ambulance company?

I would assume the hospital. They just said we are taking you by ambulance to CPMC. There was no picking or option. I should have known better. I should have asked more questions and if it was in-network. I was panicked because of needing surgery. I was just so happy that I was going to see Dr Rabkin for it that I didn't think of much else.

 

[Spiky Bugger]

"I can file a 2nd level appeal and then the next step (they are a self-funded plan) is to go to the state." One of those two statements is, by necessity, wrong. Self-funded plans are not covered by the state (either the DMHC - which your plan is not in any case, because it is BCBSIL and not Anthem or BS of CA, or its equivalent in IL).

Your route of appeal is on the denial you received, and/or in the detailed description of your Evidence of Coverage document - which you need to obtain from your employer. And you should have the right to demand an accounting of where they get their "UCR" determination, including from which state.

My question was because there was a kind of (good for a change) explanation of why I didn't need to know (for UHC PPO) who my anesthesiologist would be. PERHAPS it's because they are the secondary insurance...but they told me that since I was not the one making the decisions, they had to cover whoever the surgeon/hospital called as "in network."

 

[buffalobillsfan]

"I can file a 2nd level appeal and then the next step (they are a self-funded plan) is to go to the state." One of those two statements is, by necessity, wrong. Self-funded plans are not covered by the state (either the DMHC - which your plan is not in any case, because it is BCBSIL and not Anthem or BS of CA, or its equivalent in IL).

Your route of appeal is on the denial you received, and/or in the detailed description of your Evidence of Coverage document - which you need to obtain from your employer. And you should have the right to demand an accounting of where they get their "UCR" determination, including from which state.

Ok, so my statement says that if I'm denied for 2nd level than I can bring suit under ERISA. They do provide consumer advocates for each state. I'm not sure which to call, Illinois or California. I have also seen advocates that will take a percent of any awards they win on your case.

Ironically on the same day I received my denial I also received a letter from them stating our medical information was hacked (including SS#)!!!