15-Month battle with BCBS & QAS

[Susie Q]

I'm so disgusted & angry with both BCBS & QAS. In March of 2007 I filed a claim for the INRatio Self-Test meter & a box of 12 self-test strips. Because we were going out of the country & I knew the approval of the meter would take quite a while, I paid for it up front so I would receive it, along with the training, prior to our departure.
March 16, 2007 - Original claim denied.
April 4, 2007 - Responded with a letter of appeal to BCBS.
May 23 - BCBS reversed the denial & requested further information which I faxed to them on May 24.
June 4 - BCBS requested additional information which I submitted to them on June 5.
June 13 - BCBS requested HCPCS code which I faxed to them on June 22. Aug. 3 - Contacted BCBS to check the status of the claim. They said they'd never received the HCPCS code, so I resubmitted it on August 6.
Aug. 30 - I talked to another rep who apolized for the delay.
Aug. 31 - I faxed a 2nd Durable Medical Equipment Certification to new cardio in Houson for his signature & requested that he fax it to Baton Rouge.
Sept. 6 - BCBS rep e-mailed to verify receipt.
Oct. 2 - Received letter stating "BCBS of LA is participating in out-of-area program with other BCBS plans." Since services were rendered by out-of- state provider, claim was filed in state charges were incurred.
Nov. 27 - Called for update on claim.
Dec. 6 - Received an EOB stating "Benefits are unavailable because a certification form was not included with this claim for Durable Medical Equipment. The supplier should refile this claim with the appropriate info."
Dec. 18 - Spoke to another rep at BCBS & gave her specifics of the ineptness in this case. Every time BCBS requested additional info I was prompt in obtaining & submitting it. She "discovered" the last Med. Durable Form I'd sent.
Dec. 27 - Received letter stating they'd approved the benefits for this purchase.
Jan. 3, 2008 - Received $700.20 instead of the full amount of $1,556.00. Reason: This amt. is over allowable charge for item. Subscriber is not resp. for this amt. because provider agreed with BCBS of LA to accept the allowable charge for service rendered.
Jan. 22, 2008 - Called QAS. Betty said to fax all correspondence to her. I faxed 33 pages of documentation to her that same day.
May 6 - Faxed Betty for update on my claim. No answer.
June 11 (today) - Called QAS & spoke to Brad--relayed saga. Contacted Betty who works at home. She told Brad her supervisor told her not to go any further because QAS could not file claim with insurance if customer had personally purchased the equipment.

HELP!! I do not give up easily, but I'm extremely frustrated & aggravated. After 15 months of promptly submitting all requested documentation--sometimes submitting the same info TWICE--I am now being short-changed the remaining $855.80. Do I have any other recourse?

I have not been using my monitor & said I wouldn't until I got full reimbursement. (Yes, I'm cutting off my nose to spite my face.)

Susie Q
ATS Mechanical Aortic Valve
11/08/05

 

[901]

I've had similar experiences with BCBS!
My machine was paid for a couple of years ago because by the time I submitted the claim after surgery, I was maxxed out on out of pocket expense for that year.
The following year when I ordered strips, OAS had me pay up front and sibmit the claim to BCBS because they didn't have an agreement in place with BCBS.
Last year QAS said they would take care of it because they had an agreement in place with BCBS. However, three months later QAS started sending me bills for the full amount because BCBS had not paid. BCBS even sent me a letter stating that I didn't owe anything because the amount was beyond the contracted amount. I asked BCBS to take another look and they said OK. I called back at about monthly intervals to see what progress was being made on the reconsideration. After three reminders BCBS sent me a claim letter that said they paid about half of the price of the strips and that the rest was beyond the contracted amount.
I have not heard from QAS for awhile but I expect that I'll have problems again in the Fall when I need to reorder strips.
I think part of the problem is that BCBS does not communicate from state to state very well. QAS is located in Florida and my BCBS is located in Nebraska and BCBS of Florida and BCBS of Nebraska are on different planets!

 

[Mary]

BCBS is different for each state and is sometimes owned by different companies. In Missouri, our BCBS was bought out and became Anthem Blue Cross. In Illinois, it's BCBS of Illinois.
Two totally different organizations.

 

[jeffp]

Jan. 3, 2008 - Received $700.20 instead of the full amount of $1,556.00. Reason: This amt. is over allowable charge for item. Subscriber is not resp. for this amt. because provider agreed with BCBS of LA to accept the allowable charge for service rendered.
I have not been using my monitor & said I wouldn't until I got full reimbursement. (Yes, I'm cutting off my nose to spite my face.)

Your contract will only reimburse up to the allowable charge ($700) regardless of whether you paid or QAS billed for it. QAS ideally should have billed for it and waited for an approval. This would have delayed your unit, but solved the problem. Since your BCBS is very inept, for your health you did the right thing. QAS sold you the unit at retail where you don't get the insurer's discount. In a perfect world you'd get reimbursed. Best recourse you'd have is to put up a giant stink and have QAS excluded from the BCBS network in your state. Doesn't do you any good, and would probably be doing QAS a favor since your BCBS seems pretty lousy on paying for uncommon durable medical equipment.
Sometimes it's not worth busting a blood vessel over this type of thing (especially while on coumadin )
As to the second part of the quote above - what good is not using the monitor going to do you? It's not like you're going to return it as new.

 

[Susie Q]

15-month battle with BCBS & QAS

15-month battle with BCBS & QAS

Bouncer, thank you for trying to round up some help for me.

901, I totally agree with your statement that BCBS does not communicate very well with BCBS programs in other states. I'm in LA, & as you mentioned, QAS is in FL. Too bad a more efficient, mutual working relationship does not/cannot exist among all BCBS programs throughout the U.S. So BCBS pays only 1/2 of the cost of the test strips? I paid $156 for a box of 12 in March of last year.

jeffp, is $700 BCBS's maximum allowable charge for an INRatio monitor? When I purchased it in March of 2007, I was led to believe that I was receiving a discounted price--$1,400 instead of the $2,495 listed on QAS's website. Therefore, I thought I was saving BCBS a significant amount. If QAS knew that they would not file a claim with BCBS since I was paying for it, QAS should have been honest & up front with me at the time of purchase. Instead, they led me to believe that I would be reimbursed for the amount.

As for not using the monitor until I received reimbursement, the coumadin clinic is only 2 blocks from my house so it's really not an inconvenience to go once, sometimes twice a month. I guess, in my own stubborn way, I have been rebelling against both BCBS & QAS & subsequently trying to punish them. BCBS has continued to be charged for my visits to the coumadin clinic. QAS has not reaped any monetary benefits because I've not used my monitor or test strips except on a couple of occasions when we've traveled out of the country. I've been showing them, haven't I? My thinking is a little "off" I know. However, after battling this claim for 15 months & now discovering that almost all my efforts have been in vain, I became upset & disappointed, to say the least.

Thank the 3 of you for your help.

Susie Q
ATS Mechanical Aortic Valve
11/08/05

 

[Philip B]

Insurance Woes

Insurance Woes

Don't fee too badly about all of the problems you're having with your insurance carrier. I've got Pacificare and my attempts to get their support for a home monitor were denied. Eventually, I bought the monitor I needed, but we continued to fight with the insurance company. It took some time, but we won. Pacificare reimbursed me for the costs. We continue to fight every three months to get reimbursed for test strips.

-Philip