VSG to DS: Untimely Filing - ARE YOU KIDDING ME????

[Stefanie S.]

I am completely worn down. @DianaCox and @Larra ... have you any thoughts on this? As you know, I won my external appeal and my insurance company was ordered to pay for the surgery. However, when I went to get my money back from the hospital and my surgeon's office, because I had to pre-pay, I was told that I was set up as "self pay" and therefore insurance was not filed. I demanded that they go ahead and file. But I just got an Explanation of Benefits from BCBS that says they did NOT pay the bills due to "untimely filing". I spoke to Duke Billing (where I had my surgery) and I got this note back from them:

Hello,
Thank you for using MyChart. Unfortunately, Duke Medicine would not refund monies for a service that was understood to be denied prior to receiving it. As you indicate, and as your medical record documents, you decided to proceed with the surgery without the benefit of coverage from your insurer. We try to assist with appeals. However, Blue Cross Blue Shield denied stating it was not received in a timely fashion. This does not indicate you are not responsible for the charges. It means they will not consider the appeal. We also would not view this situation as a matter your being stuck with a debt. A service was provided. We had hoped we could have been reimbursed from your insurance, and that we would have been able to refund at least a portion of your payment. However, that did not happen. Perhaps, you may pursue an appeal with them directly. Many times insurers have a window of time for providers to appeal, but have allotted more time for their members to do so. We are sorry we are
unable to be more unhelpful in this situation.
Thank you,
Duke Health Customer Service​

Please help... what can I do? I'm in tears over this. Why, why, why?
Stefanie

 

[Spiky Bugger]

...which also means to me that they are way happier with the $ collected from a self-pay than they would be with the reduced contracted fees they would get from insurance.

I've seen $30k "amount billed" paid out as 80% of the "allowed" $4k, so the hospital gets $3200, about 10% of the billed amount. There is nothing in that calculus to cause them to want to help you.

Did you pay the entire, full-freight, self-pay amount up front?

 

[Spiky Bugger]

Wait another minute...I'm just waking up here.

You are dealing w/compound assholes?
1--insurance was told to pay, yet is denying the claim based on the fact that their delaying tactics caused the claim to be untimely filed? (I'm thinking that their BS should make them liable for the full amount you had to pay out to get the surgery that, based on the results of the appeal, they should have covered to begin with.)
2--Duke won't help because they already collected full self-pay charges from you AND apparently never considered accepting BCBS contracted payment amounts in the event you won your appeal? (Do you have anything from Duke indicating that they would accept the insurance's contracted amount in the event you prevailed at appeal?)

@DianaCox --so how much free time do you have for the rest of this year?

 

[DianaCox]

The hospital and surgeon don't owe you the money - the insurance company owes YOU the money. You need to submit your invoices to the insurance company for reimbursement.

 

[Larra]

What @DianaCox said. It was the insurer that issued all the denials, not the surgeon or the hospital. And it's now the insurer that has been ordered to pay up by your successful external appeal, not the surgeon or the hospital.

 

[Stefanie S.]

When I first heard I was finally approved, I contacted the insurer (BCBS) and told them I needed reimbursement from them. They said it didn't work that way. They said the providers would be paid and then, would reimburse me the money I paid up front to them. However, I will try that route again.

Also, side note... Diana and Larra... I can't believe I ever overlooked this, but do you know on my insurance appeals, the only amounts listed there are for the hospital, and nothing for the surgeon? So was my external reviewer's "approval" for the hospital bill only?

 

[Stefanie S.]

Wait another minute...I'm just waking up here.

You are dealing w/compound assholes?
1--insurance was told to pay, yet is denying the claim based on the fact that their delaying tactics caused the claim to be untimely filed? (I'm thinking that their BS should make them liable for the full amount you had to pay out to get the surgery that, based on the results of the appeal, they should have covered to begin with.)
2--Duke won't help because they already collected full self-pay charges from you AND apparently never considered accepting BCBS contracted payment amounts in the event you won your appeal? (Do you have anything from Duke indicating that they would accept the insurance's contracted amount in the event you prevailed at appeal?)

@DianaCox --so how much free time do you have for the rest of this year?

Amen to all of this. Especially that they are assholes. Duke has been terrible throughout the entire process. Dr. Sudan is a good surgeon, but the entire team around him - DISGUSTING how they handle nearly everything. I would not recommend them to anyone. STAY AWAY!

 

[Eztli]

I am so sorry you are going through this and I just wanted to say good luck and keep fighting. I too have BCBS and I am actually about to post about them in another thread. I keep hearing they are the best. Compared to who I wonder. I really do. After I was denied, the assistant at my surgeons office I self pay and perhaps try appealing with them myself. This thread is really making me see that doing that would be a mistake.

 

[Stefanie S.]

I am so sorry you are going through this and I just wanted to say good luck and keep fighting. I too have BCBS and I am actually about to post about them in another thread. I keep hearing they are the best. Compared to who I wonder. I really do. After I was denied, the assistant at my surgeons office I self pay and perhaps try appealing with them myself. This thread is really making me see that doing that would be a mistake.

THAT is what they told me too... and now they are totally using that against me! If you do this, get some things in writing

 

[Spiky Bugger]

@Eztli

As luck would have it...it appears that, in NC, you can record conversations with only "your own" consent. I might just want to do that if I feared that someone was trying to mislead me!

http://www.dmlp.org/legal-guide/north-carolina/north-carolina-recording-law

 

[Stefanie S.]

Just a quick update... I still have not received a dime on my claim even though my denial was overturned. BCBS is sticking with their "untimely filing" because my provider billed 2 days past their allowed 6 months for filing claims. I am in the process of appealing this. I also tried to submit a claim directly to BCBS for the full amount, but they sent back denied saying that I didn't have a Prior Plan Approval and that this process was for non-participating service providers. Needless to say, just the mention of BCBS turns my stomach.

I'm also less than thrilled with Duke Billing. They could do something to make this right as well, but they refuse. Why didn't they file my claim back in January when I had the surgery, even though insurance initially denied?

 

[Spiky Bugger]

Just a quick update... I still have not received a dime on my claim even though my denial was overturned. BCBS is sticking with their "untimely filing" because my provider billed 2 days past their allowed 6 months for filing claims. I am in the process of appealing this. I also tried to submit a claim directly to BCBS for the full amount, but they sent back denied saying that I didn't have a Prior Plan Approval and that this process was for non-participating service providers. Needless to say, just the mention of BCBS turns my stomach.

I'm also less than thrilled with Duke Billing. They could do something to make this right as well, but they refuse. Why didn't they file my claim back in January when I had the surgery, even though insurance initially denied?

Hmmm... @DianaCox @Larra...(since you both always screw with insurance companies) I wonder if the provider has some kind of obligation to file timely...and...if s/he does not, might the provider just have to eat the costs...and pay the hospital?

 

[southernlady]

Hmmm... @Diana @Larra...(since you both always screw with insurance companies) I wonder if the provider has some kind of obligation to file timely...and...if s/he does not, might the provider just have to eat the costs...and pay the hospital?

I got a couple of bills like that. The hospital/provider could not come back at me. But mine were pre-approved procedures.

 

[Larra]

I think it's worth a shot, but truth is, I don't know the answer. Diana may be more helpful.

 

[DianaCox]

Can you please set out the timeline for surgery/billing/insurance actions? Perhaps the appeal tolled the billing or something like that?