posted
UPDATE 2-12-07 SURPRISE! we received a check for $321.91 back on 5 of my 6 compounded pharmacy labs today from the RX company bcbs contracted with. of the 5 paid, they paid ALL BUT $33 FOR S/H charges!
will resend my final compounded one since i met my $250 deductible last 2-06!
so it pays to SQUEEL for reimbursements. i would have fought like heck on those RX meds.
LATEST UPDATE: 2-11-07 Hubby said bcbs rep i talked to on 2-7 called our home 2-9-07, and said she was REOPENING MY FILES ON MY "DENIED" CLAIMS
hubby said i missed her by a few minutes, so i tried calling her back, but she didn't call me back before leaving 5 pm friday.
i'll call her tuesday since i'm to be in des moines afternoon for 2 hr. hip replacement CLASS. BG
updated 2-7-07: well, since bcbs's special inquiries rep, rhea ahlburg, didn't return my call today during 2 hour span, i called their office again.
they wouldn't give me her direct no., but customer rep tried her no. said it was busy, but i could leave voice mail; so i did AGAIN!
5 minutes later, the customer service rep, denise, called me back saying, "rhea does NOT take or RETURN phone calls. she requested that i/customer service rep help you."!
told her she wouldn't be able to help me since rhea wrote 2 letters to iowa insurance commission about my complaint against bcbs. YES I CAN; RHEA GAVE ME HER 2 LETTERS.
denise didn't tell me if she had more to my file since i told denise i'd sent in 200-300 pages for review on my $4300 out of pocket expenses.
she was reading over the last letter for 1st time, and mentioned NOT getting medicare's denial letter of payment. again, emphasize, rhea never addressed my "llmds opting out of medicare form letter" she had me sign saying i would NOT send bills directly to medicare for her services!"
asked denise to tell rhea to write in user-friendly language in her letters about claims! hers were the worst i'd ever read, and i'd typed legal agreements for 25 years for a living; she would.
i told denise i didn't realize medicare was primary; bcbs was secondary until this whole mess of going out of state to a llmd who is a TRADITIONAL MD as well as a holistic md began 3-06; 11 months ago !!
i explained iowa did NOT have one full-time chronic LYME LITERATE MD IN IOWA! i called their office, and no one on their IN NETWORK LIST matching that description.
i asked her if she knew what lyme disease was? "NO, AND IT DOESN'T MAKE ANY DIFFERENCE" ! LATER, I TOLD HER IT WAS BEING BITTEN BY A TICK!
she couldn't answer anything about opted out of medicare . she wanted to give me to her supr., hillary, but i declined since i'd had dealings w/hillary since april 06. hillary lied to me over & over; i will NOT have a thing to do with that woman.
she told me her computer files show i've talked to a LOT OF FOLKS, VIPS w/bcbs and attorney w/iowa insurance commission! YES, I'LL BE TALKING TO MORE TOO!
their new explanation of benefits claim form payment is illegible; smaller than the stuff i'm always commenting on board. NOTES describing extra stuff; i had to get the magnifier out to read!
i told denise my comments on new benefits form; she'd pass it along to her TEAM leader; becky; not hillary. she'd discuss my case w/becky more.
i told her i received 3 more pages of DENIED PAYMENTS .... ZERO PAID BY BCBS; i could tell in her voice she was surprised about that.
i asked her specifically about the 6 compounded RX meds md prescribed for reimbursement. i mentioned 2 B-12 injection bottles; they're VITAMINS even if it is injection; NOT reimbursable!
told her my 3 office visits should have been covered; it was traditional treatment being given and thorough oral/family/written info given.
she asked to research my case to see if she could answer some of the questions i have.
i asked her how long that would take! "i can't tell you that; i have no idea; your problems are so broad! she would not even take a guess.
i asked her to email me results; no, they do NOT email folks. so i asked her to call me between 4-5 pm daily with the results as i'm always home during that time and off internet since we have one phone line! YES, I WILL. .
i apologized she was caught in the middle of this. " i was assigned to talk/handle this with you." she was relieved when we hung up 30-35 minutes later!
did i get any further; NO; but it showed also i contacted their office per their EOB stating i had medicare and they were primary; please contact them. i have 15 days to submit something or they will consider the bill handled!"
appeals have to be sent in within 180 days of RECEIPT of EOB; no extra paperwork to submit except their EOB denial forms with basic info: my name, address, plan no., etc.
i'll also follow up with iowa insurance commission attorney i talked to yesterday.
never a dull moment here; just 1 of my many battles going on; but it's the biggest expense for now!
DO NOT GIVE UP EVER! I'M A SQUEAKY WHEEL, AND I GET REGULAR GREASE JOBS ALL THE TIME!
UPDATED 2-6-07: funny; NO NOT REALLY, but the timing of your post is identical to what i'm going thru and received PART of my $4300 out of pocket denials yesterday for $2391!! uncanny huh?
have you tried ALSO YOUR STATE'S, MASS. INSURANCE COMMISSIONER? they are the overseers of health, life, and auto insurance? they are involved in mine, but i've NOT seen much progress although their last letter was from their ATTORNEY vs. claims specialist! he hasn't returned an email/letter since my last one last week!
your appeal letter: i have bcbs; it states in there 1st of of all to call since i HAVE MEDICARE due being approved for SSDI.
medicare is my primary; bcbs is my secondary.
llmd out of state made me sign a OPTED OUT OF MEDICARE FORM PRIOR TO SEEING ME THAT DAY IN HER OFFICE.
medicare would not send me a letter denying claims since they never received them.
i asked a claims supr. about this and told her about the opted out of medicare form; sure, send in that; that will due with EACH CLAIM; i did that.
bcbs's 2 goofy letters which were written like a lawyer vs. a claims spec. did not make sense at all but she kept emphasizing they hadn't received medicare's denial of payment letters. so they would not pay.
i kept emphasizing the opted out of medical form that bcbs rep told me to send in; they will not address that!
back to appeal; bcbs here just requires that you send in copies of their DENISED CLAIM PAYMENTS, sign their sheet comes w/it saying you are appealing, etc. NO DOCUMENTTION IS NEEDED? wierd!
I WILL BE APPEALING! bcbs offers 1 step appeal only.
i'm going to call iowa's insurance commission and ask to talk to the lawyer sending me the letter last week. he stated bcbs will send me explaination of benefits in 7-10 days; well 50% of them came yesterday.
NONE WERE FOR COMPOUNDED RX MEDS OR SUPPLEMENTS! that one will be interesting as 2 claims were for B12 INJECTION SHOTS!
back to YOUR appeal letter: you did NOT submit anything when you sent your claims?
i had a DETAILED letter stating what all was in there:
. all detailed phone calls between me/bcbs from day one when i called them 3-06 asking for the procedure of going out of state to llmd NOT in provider.
. i stated everything bcbs told me to do, and i did it.
. sent copies of medical records why i needed to go to this out of state dr. since iowa does not have one full-time chronic lyme literate md in entire state!
. sent copies of llmds 16 page q/a REQUIRED to be completed and brought to 1st 3 hr. session where it was gone over in detail BEFORE any body exam and blood draws.
. my positive lyme tetss, western blot igm and igg from igenex, calif., and my PCP's POSITIVE LYME DIAGNOSIS...CLINICAL!
. i stated why each of those should be paid.
i used my bcbs booklet detailed MY SPECIFIC HEALTH PLAN. i noted the pages stating so and so should be covered, referring to specific areas where they should coverage for ALL of the items they turned me down on.
so again, i haven't posted the above on my link yet; you beat me to it! now i'll just copy/paste over there!
MARK THE DEADLINE ON YOUR CALENDAR. get the paperwork going NOW while it's all fresh in your mind. you don't want to be too late to appeal, and they will not accept it. go as far as you have to!
also write to: your federal senators, house of reps in DC and your local senators/reps in Mass. as well as your governor and attorney general; doesn't hurt to sound off and make them aware of what you are going thru. good luck!
**************************************** I received these letters today, 1-17-07, from Iowa commission of insurance and bcbs/wellmark!
Jan. 24, 2007
Dear Betty,
Enclosed please find a copy of another letter sent to our division by wellmark explaining their handling of this situation.
Wellmark indicates they have NOT received some of your claims. They identify the claims by type and date in their letter.
Please send these claims to wellmark or through our division if you feel that would be helpful.
Wellmark also states that they are PRIORITY HANDLING the claims that they do have for you!
Please contact our division if you do not receive the explanation of benefits in NEAR future. Please also contact our division if you have further problems or additional questions.
Thank you for your continuing interest in this matter. Sincerely,
JOHN L. LEONHART, ATTORNEY Mis provided through the employer group, state of Iowa, and provides benefits secondary to Medicare.
Regarding the issue raised by Betty that I omitted info related to:
1. Dietary supplements for dates 8-1 and 8-16-06; 2. RX drugs provided by names pharmacies on 8-21-06, and 3. office and/or outpatient, and independent lab services provided on April 28, May 6, and 8-16-06.
The records rovided by betty to your office do NOT contain claims related to the above services except the reference to 4-28-06, which has a provider statement attached from Geneva diagnostics indicating that the services were provided on 4-20-06, not April 28-06.
If Betty would like to submit the remainder of these claims to our office, she may send them directly to my attention at station 52.
In reference to Betty's concerns about ``APPROVED'' OUT OF STATE BENEFFITS related to her condition of Lyme disease,
a review of our records reflects 2 te3lephone conversations with betty in which she was told that NO ``APPROVAL'' WAS REQUIRED FOR HER TO OBTAIN OUT OF STATE SERVICES AS SHE IS ON A traditional POLICY WITH WELLMARK.
In one conversation, she was offered detailed benefit info, but was advised that her benefits certificate does NOT provide specifics on LYME disease.
Our records also reflect a telephone call from a provider office (my primary card MD's RN), regarding betty's benefits for out of state care. The provider was appropriately advised that PRIOR approval for out of state care was NOT REQUIRED ON THIS CONTRACT.
Therefore, NO ``APPROVAL'' WAS PROVIDED FOR HER SPECIFIC SERVICES THROUGH THESE OUT OF STATE PROVIDERS.
Although betty's certificate does NOT require that she obtain approval when obtaining services OUTSIDE the state of Iowa, as stated in my 12-12-06 letter, this certificate does provide benefits SECONDARY to Medicare,
And wellmark MUST receive a MEDICARE REMITTANCE NOTICE, MRN, for ANY claim submitted for benefits secondary to Medicare. (betty's comment ... again, wellmark does NOT acknowledge the OPTED OUT OF MEDICARE FORM that my llmd required me to sign PRIOR to seeing/treating me!)
Wellmark is making every effort to provide feedback, IF NOT BENEFITS, to betty regarding her claims submitted to our office.
Due to LACK OF MRN on the medical clams, the lack of detailed professional HCFA-1500 claim forms,
And the fact that some of these providers are NON-CONTRACTNG with their LOCAL BLUE CROSS PLAN,
EACH claim must be MANUALLY coded for entry into our claims system.
Our efforts to process these claims has been compounded by the fact that as these services for betty were provided OUTSIDE the state of Iowa,
Her claims should have been submitted to the BLUE CROSS PLAN for the STATE in which services were rendered, (again, iowa's wellmark office SCREWED up failing to get them to THEIR blue card program; it wasn't because of me!)
And processed through the BLUE CARD PROGRAM!
I required PRIORITY HANDLING of betty's 4-20 to 9-13-06 medical and pharmacy claims!
She should receive EXPLANATION OF BENEFITS for EACH CLAIM within 10-14 days!
I appreciate the opportunity to further explain the position of wellmark of Iowa. If you have any questions regarding this info, please feel free to contact our office. Sincerely,
RHEA AHLBERG, special inquiries *********************************
More comments from betty on both of above letters:
Yes, there were a few bills i didn't submit to wellmark since they were NOT acting on any of my bills; they wore me down!
Yes, i'll submit them to the attorney who wrote me the newest letter.
It really upsets me wellmark/iowa refuses to discuss the OPTED OUT MEDICARE form i was required to sign which equals the DENIED MEDICARE FORM THEY REQUIRE said their 1-800 q/a specialist over the phone operators answering q/a!
I sent 80 more pages of medical files Monday, 1-22; so wellmark had NOT seen these which are CRITICAL TO MY CLAIMS.
They are everything i submitted to minn. Llmd PRIOR to her examining/treating me 4-10-06. It was her 20 page q/a with detailed info i submitted to admin law judge for my 2nd ss disability insurance hearing outlining my illnesses/symptoms by drs/dates, and medical reports.
So i'll send the attorney a note about my 1-22-07 pages sent to be included in the findings of approving my claims!
I was shocked the attorney wrote the letter this time!
It shows it pays to have REBUTTALS to their findings; DO NOT GIVE UP EVER! BE THAT SQUEAKY WHEEL NEEDING GREASE JOBS! Boy, am i good at that! Betty Gordon
posted
Betty,that is not bad at a glance.We had to pay $3112.00 cash,plus insurance for my husbands first two visits. We have friends that have had to pay that for the first visit to a doctor in Philadelphia.
Posts: 510 | From NEVERLAND.USA | Registered: Jul 2005
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bettyg
Unregistered
posted
i called the attorney at iowa insurance commission, market regulation bureau, filling him in briefly on above. i tried to be short and concise but he was completely baffled.
medicare not sendng denials to bcbs when llmd had me sign a OPTED OUT OF MEDICARE FORM saying i would not bill medicare for my bills.
WHY did you do that? he asked. She told me if i submitted bills to medicare, they could put her in jail.
he asked if i talked to bcbs rep; no! he was the last one who sent me something. bcbs sent 4 sheets only of DENIED BILLS .... no letter, and
"call us since it shows medicare is your primary and we're your secondary....
i called there, but spec rep was away from her desk; customer service rep took a message of what times to do call on this complaint no. w/iowa insurance commissioner.
1st call put me on hold 2-3 times and then lost me! she wouldn't put me thru to woman i wanted to talk to.
i'll keep you informed on my continuing saga; started 11 months ago mid March 06!
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-------------------- Stella Marie Posts: 694 | From US | Registered: Apr 2005
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bettyg
Unregistered
posted
update posted at top of this post:
talked to bcbs today; specialist inquiries rep REFUSED TO TAKE OR RETURN PHONE CALL TO ME; read the rest for more.
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bettyg
Unregistered
posted
update 2-9; while i was gone, bcbs rep called telling hubby she is going to REOPEN MY "DENIED" PAYMENT FILES! WHOOPIE.
i tried calling her back promptly but she didn't return my call before going home for day.
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bettyg
Unregistered
posted
UPDATE 2-12-07 SURPRISE! we received a check for $321.91 back on 5 of my 6 compounded pharmacy labs today from the RX company bcbs contracted with. of the 5 paid, they paid ALL BUT $33 FOR S/H charges!
will resend my final compounded one since i met my $250 deductible last 2-06!
so it pays to SQUEEL for reimbursements. i would have fought like heck on those RX meds.
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Geneal
Frequent Contributor (5K+ posts)
Member # 10375
posted
Yeah Bettyg!!!!!!!
I have bc/bs also. There aren't many choices here for health insurance.
Persistance certainly pays off. I hope you can get this wrapped up before your hip surgery, so you have no other worries other than getting well so you can go dancing!
Geneal
Posts: 6250 | From Louisiana | Registered: Oct 2006
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bettyg
Unregistered
posted
thank you geneal, for your positive thoughts hoping this would be concluded in 3 wks. by the time of my march 5 hip replacement surgery!
wishful thinking as slow, pokey as bcbs has been since 4-06! i can't believe it.
kicking up my heals dancing again; boy, that's been many MOONS ago!
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