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Old 11-13-2007, 11:52 AM   #21
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Originally Posted by Helena View Post
I can offer this extra bit of advice... the old
adage is true.. you will catch more files with honey... if you know what
I mean... but don't hesitate to ask to speak to the supervisor, if necessary...
and call during the day... from 9am to 3pm is best.

Let us know how it goes.
Thanks. I hear ya. I'll let you know.
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Procedures for Getting Your Proper Benefit
Old 11-17-2007, 09:59 AM   #22
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Procedures for Getting Your Proper Benefit

Here are a few thoughts that come to mind about getting what is due to you. There is great variance in the types of policies, what is covered, and how they pay. These steps should work in most cases. There is a book out there called Making Them Pay: How to Get the Most From Health Insurance and Managed Care that has plenty more information in it.

First off, there are plenty of mistakes that are made in billing. Coding things wrong or submitting them improperly can deny payment to either the provider or you. Check with the provider and insurer to see if this is the case. This is a first, simple step that can resolve a number of issues.

Second, if you can't get satisfaction in this way, the next step is a two-level appeal with the health insurance company. They have certain time frames that they respond to these two appeals, and the insurer uses this approach to find problems within their organization or with the providers, and to try to satisfy their customers (you!).

Third, if you don't get anywhere with the insurer, or are getting the "run-around", contact your state department of insurance. I've got contact information for each department of insurance on my website. Most states have a formal complaint process in addition to a hotline for advice before you have to go with a formal complaint. I've never had to do this, but according to my sources, this step will really get the attention of the insurer, and they will try to resolve the issue. Results of these complaints are compiled and statistics are published about each insurer. The statistics are known as the "complaint ratio" and tell the state and the world how well an insurer is doing. You can get an idea of the types of complaints and how they are resolved from the consumer information section of the website for the National Association of Insurance Commissioners (National Association of Insurance Commissioners).

Best of luck resolving your issues. Let me know if you need further resources.
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Old 11-17-2007, 03:56 PM   #23
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Best of luck resolving your issues. Let me know if you need further resources.
Thanks for the information!
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Old 11-18-2007, 03:25 PM   #24
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If it is "in network" and they have a negotiated rate that is what the insurance pays but you are not liable for the difference. When we had this happen, I called the insurance company and that is what they told me, I then contacted the doctor, hospital, etc., and told them what the insurance co. said. I told them we weren't responsible for the difference, they have a negotiated rate and that is what they received, and that we wouldn't be paying any of difference. It was never a problem.

I got the impression some doctors, hospitals, labs try to bill the patient because sometimes the patient will pay the difference and that's extra money for the them.
That is exactly what happened to me - paid the Co-pay to the In-Network doctors (There were THREE that did this). Docs get paid by BCBS according to their negotiated contractual rate, then Docs bill me for diff btwn the BCBS rate & their "normal" rate. I told them I wouldn't pay as they were paid their contract rate. They tell me that in this region the negoiated rate in unreasonable so I am responsible for the difference. I say "a contract is a contract" - they told me they'll be putting it out for collection if I don't pay.
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Old 11-18-2007, 03:50 PM   #25
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That is exactly what happened to me - paid the Co-pay to the In-Network doctors (There were THREE that did this). Docs get paid by BCBS according to their negotiated contractual rate, then Docs bill me for diff btwn the BCBS rate & their "normal" rate. I told them I wouldn't pay as they were paid their contract rate. They tell me that in this region the negotiated rate in unreasonable so I am responsible for the difference. I say "a contract is a contract" - they told me they'll be putting it out for collection if I don't pay.
Take the complaint back to BCBS. Docs can't do this.
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Old 11-18-2007, 04:06 PM   #26
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Take the complaint back to BCBS. Docs can't do this.
I agree. Maybe someone with first hand knowledge will chime in, but I thought the agreements with BCBS, etc. required docs under the agreement to accept the contract amount.
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Old 11-21-2007, 07:15 PM   #27
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If the provider is a BCBS provider, he signed a contract with BCBS to accept the BCBS allowed amount or negotiated amount (less any copay or deductible) as payment in full.

If the provider does not follow the contract they signed, contact your BCBS and let them know. They should contact the provider and remind him of his contract, and tell him what he needs to accept on your claim. If the provider continues to be a problem, their Provider relations department will most likely contact him.
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Old 11-26-2007, 10:55 AM   #28
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Who can help?

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Originally Posted by KB View Post
If the provider is a BCBS provider, he signed a contract with BCBS to accept the BCBS allowed amount or negotiated amount (less any copay or deductible) as payment in full.

If the provider does not follow the contract they signed, contact your BCBS and let them know. They should contact the provider and remind him of his contract, and tell him what he needs to accept on your claim. If the provider continues to be a problem, their Provider relations department will most likely contact him.
This is a tough one.

The insurer appears to be following the rules, so you can't complain to the department of insurance, although they might be able to tell you who to complain to. To find your state department of insurance, you can go to: National Association of Insurance Commissioner's Link to Your State Insurance Department Site. I've got a quicker list to find your department of insurance's health insurance section - if I knew your state or somebody asks for a link I can post it.

The state medical regulators are more concerned with quality of care than billing practices, so that might not be a good course.

The insurer can put pressure on the provider, but can't prevent them from putting your account to collection (incorrectly in my opinion). You can win a lawsuit or counter lawsuit, but then who do you end up getting medical care from?

Perhaps this is a bigger issue in your area, since you state that there were 3 different providers (different offices?) with the problem. The last thing that comes to mind is the state attorney general who may find some practice that is going wrong and can make a difference.
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