BCBS denied my claim (Shingles Shot)

[mpeirce]

Just another data point:

I got my shingles vaccination this year (age 53 at the time) and it was covered by BCBS (Ohio, not Illinois).

Of course, it was administered at my PCP's office so I guess he approved it...

 

[Sue J]

DH, age 60, just got his shingles shot 2 weeks ago. It should have been simple, but no……..

Do you have a minute?

I called our insurance company a few weeks ago to make sure this was covered and how to proceed. Yes, it's covered without a deductible, just ask for it at your doctor's office or take a prescription to a network pharmacy. Sounds simple and straightforward.

DH had a Doctor's appointment and asked for the shingles shot. They don't do them at the office, the doctor will send in a prescription, what's your local pharmacy?

DH gets home from the visit and gets a phone call from our mail order pharmacy. Your doctor sent a prescription for the shingles vaccine but we only do mail order medications. DH calls the doctor's office and tells them of the error, they resend, this time to a local CVS pharmacy.

DH goes to the local CVS and asks for the shingles vaccine. They take his insurance card but it comes back as not covered. They try again, it’s still denied.

DH comes home and I call the insurance company again . Yes, it’s covered, have the pharmacy process it as MEDICAL, not PHARMACY. Ok, that makes sense.

The next day DH goes back to the pharmacy and asks for the shingles shot, please be sure to process this as Medical, not Pharmacy. It’s still comes back as not covered. Would you like to pay $247.99? No thanks.

DH is quite perturbed by now. He’s retired and this is the most stress he’s had in a long time. It's already late Friday afternoon. We will deal with this next week. Ugh.

Before dinner we need to run an errand at the grocery store and while we are there I ask at their pharmacy, “Do you have the shingles vaccine and what’s the process to get it? We have been dealing with CVS and even though our insurance says it’s covered with no deductible CVS can’t get it to process correctly.” “Sure, let me see your insurance card.” We wait about 2 minutes and she comes back and says,”Yes, this is covered with no deductible, no copay, it just needs to be approved by our central office. I can send that in and call you when it’s processed, probably early next week.” DH says he can pick up a printed prescription from his doctor and bring it in and she says they don’t need that.

Wow, what a difference! So we went home and had dinner and soon after that the grocery store pharmacy calls and says it’s all approved and you may come in at your convenience, by the way, we are open until 9pm.

DH put some shoes on and went right up and got his shot, and a receipt showing no payment, no copay due. I have not seen this claim show up on the insurance site yet, so I will have my fingers crossed until I see it processed and paid in full.

 

[youbet]

Just another data point:

I got my shingles vaccination this year (age 53 at the time) and it was covered by BCBS (Ohio, not Illinois).

Of course, it was administered at my PCP's office so I guess he approved it...

That seems to be the issue with OP's situation. The rule says prior approval. He didn't get prior approval. But I still think a formal appeal would be worthwhile.

 

[youbet]

DH put some shoes on and went right up and got his shot, and a receipt showing no payment, no copay due. I have not seen this claim show up on the insurance site yet, so I will have my fingers crossed until I see it processed and paid in full.

Don't worry about the insurance at this stage. You have a receipt from the drug store saying "no payment, no copay due." You're done. If they bill you, forget the insurance company, just show them the receipt they issued. All done.

BTW, I chuckled over the earlier issues..... even your doc screwed up by sending the prescription to mail order.
I think I'm going to have mine done at the doc office if possible......

 

[easysurfer]

Was does the insurance policy say about needing a PCP's referral or not? I think that is the key. Gone are to good old days I think where a BCBS card was the standard bearer.

I remember last year just signing up with them was such a headache. Trying to get a policy with them on the phone and the person getting stuck in the application saying computer problems, not sure why. I finally applied through ehealthinsurance.

This year, I'm going with a BCBS plan from the markeplace but my confidence isn't that high that they won't get confused in the process. Fingers crossed.

 

[Bestwifeever]

That seems to be the issue with OP's situation. The rule says prior approval. He didn't get prior approval. But I still think a formal appeal would be worthwhile.

I think the saga in the OP's first post here implies prior approval in that several people in the insurance company told him it was covered and knowing his insurance status, still told him to get it at the pharmacy, not to get the PCP approval first. In that case I think the insurance company should cough up. And the conversations were probably recorded (I always get a recording before being connected to insurance companies that the call will be recorded "for quality assurance"), so BCBSIL can call up the recordings to verify.

Not pertinent, but I did get a shingles shot a few months ago (in doc office, insurance paid) and recently got a very mild case that lasted only a week.

 

[RetireAge50]

We had an insurance dispute (different issue) where calls and emails were all denied. Wrote a letter and a check arrived in our mail. I had shingles about 10 years ago and it was the most pain I had ever gone through. If you never get shingles the $217 is the the best decision you ever made.

 

[ziggy29]

This year, I'm going with a BCBS plan from the markeplace but my confidence isn't that high that they won't get confused in the process. Fingers crossed.

Especially since in many states, they don't even offer PPOs any more -- only HMOs which require the PCP to be the gatekeeper to all other approved care and services.

 

[audreyh1]

Especially since in many states, they don't even offer PPOs any more -- only HMOs which require the PCP to be the gatekeeper to all other approved care and services.

It's amazing that BCBS didn't tell ER50 up front that he had to go through his PCP first, if that's the most basic rule of an HMO.

 

[ziggy29]

It's amazing that BCBS didn't tell ER50 up front that he had to go through his PCP first, if that's the most basic role of an HMO.

Yeah. It might not help in this case, but this is why, in the absence of recording a call, I at least note the date, time and name of the CSR on the other end of the line.

 

[Amethyst]

Hmm...it sounds like he is blessed with a rather settled life in retirement. Then again, perhaps ours has been unusually stressful.

Good luck!

DH is quite perturbed by now. He’s retired and this is the most stress he’s had in a long time..

 

[W2R]

DH put some shoes on and went right up and got his shot, and a receipt showing no payment, no copay due.

I am so happy for the two of you! It sounds like the grocery store pharmacy took care of the problem when CVS either couldn't or wouldn't.

I can sure understand why this has been so stressful for your DH and probably for you, too. I think the most stress in my 6+ year retirement was due to a similar insurance/medical confusion several years ago (that is also now resolved). I think that for me, it would have been less stressful to be held up at gunpoint for the $350 that was in question.

 

[ERD50]

Yeah. It might not help in this case, but this is why, in the absence of recording a call, I at least note the date, time and name of the CSR on the other end of the line.

I did get the name and time date of each call, and for the second call, where she said it would be covered, I got a ref# for the call.

Of course, that was all ignored! I think they just have the equivalent of a "Chatty Kathy" doll, with only one recording "You are denied!".

But I will try the appeal process. First, I'm going to call my Doc's office, and see what they say. There's something about the actual billing goes through the HMO, so I don't know. All very confusing.

It's amazing that BCBS didn't tell ER50 up front that he had to go through his PCP first, if that's the most basic rule of an HMO.

Right. I'm new to this, and my call was basically to find out if there were age or other restrictions. So when they told me to just go to Costco and it is 100% covered, I believed them!

-ERD50

 

[Chuckanut]

Sometimes I think that the folks who run the financial side of the medical industry are all lined up in front of the Congress and the White House, screaming in loud voices "Please regulate us! We need more rules, more standards and many more bureaucrats to tell us what to do and how to do it."

These boys and girls need to get their act together. They are their own worst enemy.

 

[karen1972]

Just for the record, not all states allow such a wide latitude. In some states both parties must consent in advance. This tripped me up once when I planned to record an in-person conversation. My attorney strongly advised against it based on the law of that state. Maybe phone calls are under a different law, but I doubt it.

Yeh the laws are VERY different in every state. That is why when you call into those places, they have to immediately state, the phone call will be recorded, if you don't wish for it to be recorded, blah blah blah. and if you are calling an insurance company you have no idea what state the person on the other end is actually in.

 

[youbet]

I think the saga in the OP's first post here implies prior approval.

Well, OP will have to clarify. If the BCBS phone rep clearly stated that he/she was approving the shot in lieu of the doc, then BCBS is clearly in error with the denial. If the phone rep was answering questions regarding the in-network status of the pharmacy or whether OP's age disqualified him for the shot, then OP has an issue: he didn't get prior PCP approval.


But, OP will have to clarify I guess. The phone rep would have had to clearly and directly state he/she was authorizing the shot in lieu of the PCP, not just imply that indirectly.


In any case, if prior approval is the issue, OP can appeal. DW did that years ago when she was with an HMO and got them to make an after the fact exception. The situation was very similar to OP's.

 

[Chuckanut]

I read his post as saying he called to find out if the shot was covered due to his age and at that particular drug store. I don't he called and asked to be excused from the prior approval rule. Thus, I think that's the issue. The BCBS agent could (and should) answer questions about whether his age is OK, the drug store is in network, etc., without granting approval in lieu of the PCP.
.

My guess is that the OP would say that the rep should have advised him to get the prior approval along with answering the questions. I would agree with that view.

 

[mpeirce]

Sometimes I think that the folks who run the financial side of the medical industry are all lined up in front of the Congress and the White House, screaming in loud voices "Please regulate us! We need more rules, more standards and many more bureaucrats to tell us what to do and how to do it."

These boys and girls need to get their act together. They are their own worst enemy.

Of course they aren't. The big companies DO want more regulation. They have the money to move the regulations in the direction that benefits themselves.

Regulatory Capture Definition | Investopedia

 

[RE2Boys]

Not to change the subject matter, but I've recently found that it was much more effective to just go with the formal appeal process when disagreeing with the medical insurance companies.
In the past, I've tried dealing informally with phone calls to the insurance folks, doctor's offices to give insurance company more complete info, etc but with real mixed success.
Recently each of my sons was injured, one a concussion, the other had his hand stomped on.......they both play soccer. My insurance contract has a clause that any medical within 72 hours of accidental injury is covered 100%. The real trick is to get the multiple medical entities (hospital, ER doctor, follow-on doctor, radiologists, etc) to each provide the appropriate info to the insurance companies so that it labeled an accidental injury. ER is usually pretty good but the rest always act clueless when I tell them to be sure to use "codes" or whatever to label the injuries as accidental.
This fall, I just wrote two letters invoking the formal dispute process pointing out that many billings should have been paid at 100% per paragraph xx.x.
To give credit to BC/BS, they got back to me in about two weeks to discuss, I explained what happened and sequence of events (repeating what was in my letter). Took them a couple of weeks to gather more info from the providers, and just yesterday received an EOB showing the last of the claims was paid in full.
In the future, I'm just going the official route, much less hassle other than putting together a complete and accurate letter to kick things off.

 

[youbet]

My guess is that the OP would say that the rep should have advised him to get the prior approval along with answering the questions. I would agree with that view.

That would be nice, but it's not what my experience has been. The insurance companies don't seem to want to staff the phone lines with reps that are authorized to listen to a verbal description of what the customer wants to do and then approve/disapprove and, if approve, pass out an authorization number. Nor do they seem to want to sign up to "if we don't tell you no, then it's yes" situations. Or "if you had a responsibility in the process and we failed to remind you of it during a call" then you're excused from the responsibility.

I'm not sure if their hesitancy to push decision making authority down that low (to the phone clerks) is because they are afraid there would be lapses in consistency or what, but that's the way it seems to be.

Believe me, I sympathize with OP. It's frustrating. That's why I'm glad we're off HMO plans right now. (Although DW is on a Medicare Advantage plan which isn't far from being an HMO.) The rules requiring PCP approval for everything are much more non-negotiable than most clients want to believe (including DW and I at one time).

Still, I'm betting OP can get an exception authorized via a formal appeal. But it'll never happen through informal emails and phone calls. I thought the appeal process was fairly straight forward and worked pretty well. And I can understand why the company needs to restrict exception making to a well defined group of employees who must document the details.

 

[youbet]

but I've recently found that it was much more effective to just go with the formal appeal process when disagreeing with the medical insurance companies...........

In the future, I'm just going the official route, much less hassle other than putting together a complete and accurate letter to kick things off.

+1

 

[ERD50]

Well, OP will have to clarify. If the BCBS phone rep clearly stated that he/she was approving the shot in lieu of the doc, then BCBS is clearly in error with the denial. If the phone rep was answering questions regarding the in-network status of the pharmacy or whether OP's age disqualified him for the shot, then OP has an issue: he didn't get prior PCP approval.


But, OP will have to clarify I guess. The phone rep would have had to clearly and directly state he/she was authorizing the shot in lieu of the PCP, not just imply that indirectly.


In any case, if prior approval is the issue, OP can appeal. DW did that years ago when she was with an HMO and got them to make an after the fact exception. The situation was very similar to OP's.

Well, I wish I had recorded it myself, but here's what my shorthand notes to myself on the call say:

I ask about Zostavax - he says Immunizations- covered - preventative

I ask: Deduct? then write No cost to me

I ask: How? (and I think I mention that I've used Costco pharmacy before, are they OK)--- he says Costco (he gives me my local Costco pharmacy address). End of notes

And this little exchange took 30 minutes, he put me on hold several times to check things!

So as I recall, I simply asked if there were any age restrictions on getting this vaccine, and if it is covered, and then I asked how I go about getting it. I want to make sure I'm following the right process for it to be covered. If I needed PCP approval, he should have told me that, but he said I could just go to Costco. No mention of prior approval from PCP.

I was not just asking if Costco Pharmacy was in-network or not, I already knew it was, as I had a prior prescription filled there, and I told him that - I said it was convenient for me and I've used them before. I wanted to know if I got this shot there, would it be covered.

This insurance policy is new to me, and I had not even used any aspect of it at this point (other than paying the premium each month!), I should expect the business to know their policy better than I do. If I needed prior approval through the PCP, then they should have told me.

I don't know if that's any clearer than the OP or not, that pretty much covered it. Without an actual recording, I can't say exactly what was said.

But I will follow up with the actual appeal process. Thanks.

-ERD50

 

[youbet]

I wanted to know if I got this shot there, would it be covered.

. If I needed prior approval through the PCP, then they should have told me.


-ERD50

Errrrrrr.........

I understand your frustration since you probably haven't studied the info book and haven't yet gained knowledge through experience working with this HMO and the various providers. But, the doc pre-approval thing is sooooo prevalent in HMO's, I bet the low level clerks, like the guy you were dealing with, stop mentioning it as a part of every single question they field.

Put the other way around (and I admit I'm doing the "tough love" thing here so please don't take offense) you should have asked if you needed pre-approval. You know you're with an HMO, right? Why did you think this would be an exception? Needing pre-approval is pretty routine.

Your question regarding whether the shot would be covered at that particular drug store doesn't clearly call for an answer as to whether that procedure is a rare exception to the HMO "pre-approval" doctrine. You need to be more suspicious, more cynical. It will never be as simple as a low level clerk telling you "yeah, sure, it's covered, no problem."

Anyway. I've been through similar to what you're dealing with more than once. It makes sense that this can't be cleared up via informal email and phone calls. Submit your appeal and I'm betting you have a excellent chance of winning. But they aren't going to issue an exception informally. They just don't delegate that authority at the level you're dealing with due to gov't compliance and consistency issues.

Crank the handle. Submit the paper. Stop emailing, calling and fretting it for now. You'll get an official answer in writing.

Maybe a glass of some seasonal spiced brew would help?

 

[ERD50]

Errrrrrr.........

I understand your frustration since you probably haven't studied the info book and haven't yet gained knowledge through experience working with this HMO and the various providers. But, the doc pre-approval thing is sooooo prevalent in HMO's, I bet the low level clerks, like the guy you were dealing with, stop mentioning it as a part of every single question they field.

Put the other way around (and I admit I'm doing the "tough love" thing here so please don't take offense) you should have asked if you needed pre-approval. You know you're with an HMO, right? Why did you think this would be an exception? Needing pre-approval is pretty routine.

Your question regarding whether the shot would be covered at that particular drug store doesn't clearly call for an answer as to whether that procedure is a rare exception to the HMO "pre-approval" doctrine. You need to be more suspicious, more cynical. It will never be as simple as a low level clerk telling you "yeah, sure, it's covered, no problem."

Anyway. I've been through similar to what you're dealing with more than once. It makes sense that this can't be cleared up via informal email and phone calls. Submit your appeal and I'm betting you have a excellent chance of winning. But they aren't going to issue an exception informally. They just don't delegate that authority at the level you're dealing with due to gov't compliance and consistency issues.

Crank the handle. Submit the paper. Stop emailing, calling and fretting it for now. You'll get an official answer in writing.

Maybe a glass of some seasonal spiced brew would help?

No offence taken, but I haven't been in an HMO for probably decades (I think that was an option with MegaCorp years ago, maybe I'm even mis-remembering that), and even at that, are HMO's from decades ago the same as today? I sure don't know that. I am ignorant in this area, I admit that. That's why I called!

No, I don't know every detail about the PCP approval thing. I know you need to go 'in-network', that is very clear on every single thing, I couldn't miss that. And I know that you can't see a 'specialist' w/o referral from your PCP, that was clear to me. But I honestly thought that preventative care of this sort, when it was emphasized to me that there was no charge at all, and no mention to me of PCP approval requirement, would not be in the same level. Heck, it's just a shot, not brain surgery!

And remember, this was my very first interaction with this coverage, other than paying my premium. I did not know what I did not know. When I looked though the docs they provided, and searched online, there was nothing specifically under 'shingles' or 'Zostavax'. I knew from here and other places, that some insurance coverage had age restrictions. I could find nothing age related in regards to immunizations. Again, that is why I called. And when I was told no charge, I tried to verify the procedure with them, and again, no mention of pre-approval.

I'm not all that worked up (other than just frustrated at BCBSIL), just trying to give the background here why I felt that BCBSIL should have told me about the pre-approval process when I called. It's not like I just called, and asked if Costsco was an in-network Pharmacy, heard 'yes', and hung up. I asked about the process, and had him repeat several times that there would be no charge if I just go to that Costco and get the shot.

Clearly, I understand this pre-approval for everything now. And before DW gets here Shingles shot, we know what to do. But I didn't at the time, and it sure seems to me the BCBS rep should tell you what you need to do to meet his 'no charge' requirements, like did you see your PCP first!

Not much of a seasonal spiced brew kinda guy, but I'll find something interesting later.

-ERD50

 

[youbet]

Clearly, I understand this pre-approval for everything now. -ERD50

Settle down big guy....... ! No need to convince me of anything. I'm just discussing what I think are the ways you have to handle HMO bureaucracy. Not how the bureaucracy should be able to be handled if things were set up right.

This stuff happens. I'd relate a few similar (but way more $$$ involved) I've been through going all the way back to my MegaCorp insurance and right up to recently with DW's Medicare Advantage plan, but I'd be typing all day and everyone would be more than bored. I'll just say the biggest nightmare involved my son developing arnold-chiari as a teen and while our med coverage was a MegaCorp provided HMO. Auuuuuugh! A life threatening condition vs. a sometimes balky HMO. It was a true nightmare.

Assume you need pre-approval for everything except going in to see your primary care doc. He/she doesn't need to pre-approve him/herself. And I suppose granting an appointment is "approval" for you to come in.

Be cynical and suspicious. Phrase questions after you think about whether your wording will get you the required info or not. Put little faith in phone clerks. If you must call, assume the person on the phone is a minimum wage temp worker who had a day of training but didn't pay attention. (An overstatement, but the safe way to look at things.)

Keep things in perspective. This is a couple hundred bux. Irritating but "yawn." Focus on understanding what you need to do to manage your HMO coverage if you or DW need extremely expensive, urgent care. Arm wrestling over $200 is one thing. $200,000 is another.

This too shall pass. Submit the appeal in writing per procedure. Keep emotion and lectures about the quality of their staff out of it. "Just the facts." I'm betting you win and the worse part of the whole thing will be that you let it get under your skin a bit. ( I do the same thing.)