Blue Cross Blue Shield International Denied Claim based on Non-existent Codes

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Oct 30, 2018
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#1
In 2009, following a serious fall while traveling in Germany, I was told by a radiologist, a friend of the family, that I would need urgent surgery to replace a broken hip joint that was about to fuse and collapse at any moment. I called BCBS to notify them of the bad news, and was assured by two separate reps in two phone calls that the claim would go as smoothly as if the surgery were done in the USA. There was no issue of participating physicians or facilities because there were none in Germany and it would have meant certain crippling or worse if I had to drag a broken hip across Europe to find a facility that was in network. This was a "surprise" occurrence and there was no time to shop for a BCBS provider. On October 16th, 2009 the hip was replaced. Following 11 days in the hospital and 4 weeks in residential rehab to regain strength, fight anemia from blood loss due to extended time in surgery, and learn to walk with crutches, I flew home to NYC to celebrate a very grateful Thanksgiving and Christmas holiday with family. After the holidays, I submitted the claim to Blue Card Worldwide International in Virginia, per instructions from BCBS and attached all relevant paper backup for services rendered. What ensued was not weeks, nor months but years of claim form hell. They insisted that I was required to include International Codes for services rendered, but to this very day, BCBS still doesn't "get it" that THERE ARE NO INTERNATIONAL CODES OUTSIDE THE USA, JUST AS THERE IS NO TRUE WORLD SERIES OF BASEBALL OUTSIDE THE USA. Incredulous, for several years I kept up a dogged flow of resubmissions, replies and copies of documents they had already received, phone calls to BCBS NYC, and faxes. Then my precious 35 year marriage ended in divorce, I was diagnosed with breast cancer and began treatments to reduce the tumors, underwent a double mastectomy and then had to care for my mother who succumbed to paralysis and a steep decline into dementia. I couldn't do much of anything that wasn't absolutely necessary to keep myself and my mother alive. I felt like a lepper. Much of that time is still a blank and I am still my 90 year-old mother's caretaker. I am astounded to be alive at this point, so I am asking anybody with good information to help me get my money back from a company in which I had been a policy-holder for decades. The inexcusable, protracted delay was not mine but theirs in this very well-documented, timely claim. The stonewalling was not mine but theirs and the stupefying incompetence is theirs as well. Shame on you Blue Cross Blue Shield, for adding even more misery to the worst days of my life.
This Spring, after hounding Emblem Health GHI, my supplemental, for their part in the same claim, I was told by a Schenectady-based rep that my "last chance" would be to go to NYC for a face-to-face with their downtown customer service rep at their walk-in center. Alleluia!! I put the cart before the horse praying that the supplemental would "get it" even if BCBS was still stonewalling me, packed about 20 pounds of back-up documents in a backpack, boarded a bus and went across two states to speak with a customer service V.P. who was only there for one day. I prayed the whole 2 1/2 hour trip. She heard my story, thank God, and was appalled. Within two weeks, I received over $6 thousand in supplemental claim reimbursements and she even reimbursed me for the bus ticket that she said was a totally unnecessary purchase, angrily insisting that her people should have resolved this claim years ago over the phone. I am hopeful for a similar outcome with BCBS, which owes me at least $25,000 in arrears and should face heavy fines for apparently hoping I would die rather than bother them any more for what is rightfully mine. Can you help me to get BCBS to step up and do the right thing as my supplemental, Emblem GHI, did? Many thanks for any help you can provide, because I can't afford to sue a giant corporation and shouldn't have to.

Edited by a moderator at op's request
 
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jsn55

Verified Member
Dec 26, 2014
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#2
If you are a resident of New York State, contact the NY Insurance Commissioner. Compose a concise listing of the facts. Your situation seems quite straight-forward to me. Try to leave all emotion out of your narrative. Call the Department of Insurance and get a name for your email. Insurance people get up every morning hoping to deny as many claims as possible; that's their job. They hope you'll get tired and go away. You have been through absolute hell and this bolluxed up claim has certainly not helped. If you want to run your email by us first, just post it and we'll be happy to look it over. You deserve some consideration and I hope that the state insurance officials can help.
 
Sep 19, 2015
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#3
Could they mean the codes used by World Heath Organization for classification and statistics? Whatever they are referring to, this should have not dragged on for so long. Please follow JSN55's advice, as you deserve to be reimbursed.
 
Oct 13, 2015
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#5
I believe the codes BCBS is referring to are procedure and diagnostic codes. For instance, if I get an eye exam tomorrow where I'm a new patient, my insurance would be billed for a new patient routine eye exam, refraction, and maybe visual fields because of my medical history. Each has a procedure code associated with it. The optometrist will find that I have myopia, astigmatism, and presbyopia and each has a diagnostic code associated with it.

Fun fact--there are some really wacky codes out there like burn due to waterski on fire, spacecraft collision injuring occupant, struck by duck, struck by macaw, and walked into lamp post.
 
May 15, 2016
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#6
it sounds like the problem is the diagnosis codes. ICD stands for International Classification of Diseases, and is an international coding system. The problem may be that the USA kind of goes their own way on this, like we use inches and pounds, while the rest of the world is on the metric system. The current system is ICD-10 in the US. In 2009 we used ICD-9. We converted only a few years ago, whereas the rest of the world has been on ICD-10 for a very long time, and I believe they are now on a newer version than us again. You may need a health care advocate, or you can do a lot of googling for "ICD-10 fracture, hip" for instance. Blue Cross would have probably paid this years ago if they had a proper diagnosis code to go by instead of arguing with them - 9 years later, I see this as a very long reach to get paid.
 
Oct 30, 2018
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#7
it sounds like the problem is the diagnosis codes. ICD stands for International Classification of Diseases, and is an international coding system. The problem may be that the USA kind of goes their own way on this, like we use inches and pounds, while the rest of the world is on the metric system. The current system is ICD-10 in the US. In 2009 we used ICD-9. We converted only a few years ago, whereas the rest of the world has been on ICD-10 for a very long time, and I believe they are now on a newer version than us again. You may need a health care advocate, or you can do a lot of googling for "ICD-10 fracture, hip" for instance. Blue Cross would have probably paid this years ago if they had a proper diagnosis code to go by instead of arguing with them - 9 years later, I see this as a very long reach to get paid.
Thank you for your input. You are correct about the codes, which I tried to learn in order to satisfy BCBS (Emblem GHI required no codes, btw, when I went to the face-to-face this Spring in NYC). The staff people I spoke to in the German Hospital in which the surgery was done thought I was kidding when I mentioned the codes. The family-friend-radiologist was baffled as well and at that pointI knew him for 20 years, so he would not have misled me. They thought it was preposterous and never heard of the use of codes for the dozens of services/treatments/visits, etc. they provided to me. There are literally thousands of codes that are very specifically connected to how the services are written up by the providers. There was no way for me to become an expert in these codes, try as I did. They insisted code systems were not in use in their country, and the 2 BCBS reps I spoke to said nothing about codes either. Considering how everything was handled by BCBS, they would not have accepted code numbers from me anyway, and that's when it just got to be too much for me.
 
Oct 30, 2018
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#8
I believe the codes BCBS is referring to are procedure and diagnostic codes. For instance, if I get an eye exam tomorrow where I'm a new patient, my insurance would be billed for a new patient routine eye exam, refraction, and maybe visual fields because of my medical history. Each has a procedure code associated with it. The optometrist will find that I have myopia, astigmatism, and presbyopia and each has a diagnostic code associated with it.

Fun fact--there are some really wacky codes out there like burn due to waterski on fire, spacecraft collision injuring occupant, struck by duck, struck by macaw, and walked into lamp post.
Thank you for your input. You are correct about the codes and how they are assigned, but this is done by trained people or the codes get bounced out and have to be corrected. Germany did not use ICD codes at the time of my surgery. Can you imagine a patient trying to match the hundreds of codes correctly? I actually tried to do that but it all became too much. BCBS also denied based on not having received a copy of the bill. They got the bill at least three times, itemized, translated and easily understood, if they had been competent and honest enough to accept that. On three submissions that followed the initial submission, I wrote in big letters across the pages "THIS IS THE BILL". Payment denied.
 
Oct 30, 2018
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#9
If you are a resident of New York State, contact the NY Insurance Commissioner. Compose a concise listing of the facts. Your situation seems quite straight-forward to me. Try to leave all emotion out of your narrative. Call the Department of Insurance and get a name for your email. Insurance people get up every morning hoping to deny as many claims as possible; that's their job. They hope you'll get tired and go away. You have been through absolute hell and this bolluxed up claim has certainly not helped. If you want to run your email by us first, just post it and we'll be happy to look it over. You deserve some consideration and I hope that the state insurance officials can help.
Thank you for your advice. I am no longer a resident of NYS, having moved to PA to care for my parents. I will take your advice and contact the authorities, etc. I would love to run that email by you and ask for your input. Thank you so very much for your kind support.
 
Oct 30, 2018
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#10
Thank you all so very much for your advice and encouragement. It means the world to me, and may also mean a refund of $25,000. Should that happen, a nice fat check will be heading to elliott.org in gratitude for the support I have already received from you all. No ICD codes needed.
 
Oct 30, 2018
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#11
Could they mean the codes used by World Heath Organization for classification and statistics? Whatever they are referring to, this should have not dragged on for so long. Please follow JSN55's advice, as you deserve to be reimbursed.
Thank you, Christina H.. I will do that.
 
May 15, 2016
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#12
Thank you for your input. You are correct about the codes, which I tried to learn in order to satisfy BCBS (Emblem GHI required no codes, btw, when I went to the face-to-face this Spring in NYC). The staff people I spoke to in the German Hospital in which the surgery was done thought I was kidding when I mentioned the codes. The family-friend-radiologist was baffled as well and at that pointI knew him for 20 years, so he would not have misled me. They thought it was preposterous and never heard of the use of codes for the dozens of services/treatments/visits, etc. they provided to me. There are literally thousands of codes that are very specifically connected to how the services are written up by the providers. There was no way for me to become an expert in these codes, try as I did. They insisted code systems were not in use in their country, and the 2 BCBS reps I spoke to said nothing about codes either. Considering how everything was handled by BCBS, they would not have accepted code numbers from me anyway, and that's when it just got to be too much for me.
I can tell you what I know from personal experience dealing with an overseas bill and also as a doctor. Every single line of a bill in the US has to have a diagnosis and a procedure. The diagnosis is an official ICD-10 code. No insurance pays any bill without it, and never did, since at least the '70's. There is a misunderstanding on your part re: Emblem GHI, as well as a misunderstanding with your radiologist friend, (although the radiologist is probably an employee and has nothing at all to do with billing). From personal experience, if you had taken that very first bill in 2009 and translated it in handwriting as you did, and looked up a single ICD-10 code for fracture, hip (and it was much easier then with ICD-9) and handwritten that code somewhere on the bill, it would have been paid in 6 weeks. My wife had a tibial fracture (among other things) on a ski vacation, and we submitted the bill just as I wrote above to our local BC/BS and they paid it promptly. There were actually multiple diagnoses, but you only need one to get paid. I forget if you said that you had CPT procedure codes - they are also necessary and are a bit harder than the diagnosis codes, as you do need one for each thing you want to be paid for.
 
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Oct 30, 2018
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#13
I am grateful for your input, but baffled by your advice. How is an American who had surgery in a foreign country supposed to know a proper code, or codes, for the hundreds of procedures and services that are performed over a six-week stay in hospital and rehab facility in the foreign country? Why would my two BCBS reps NOT have told me I should write a code, or codes, and which one(s), on the bill? I am sure I am not the first BCBS subscriber to have had urgent hospitalization in a foreign country and sent in a claim to BCBS. How is a patient, with zero information on codes after dozens of contacts with the insurance company and denials, not given an idea, even, of which code/codes to apply in a foreign case? So, if what you are saying is correctly understood, I would have had to do my own codes, or write a singe code on a bill? Believe me, if I had known about writing a code on a bill....By the way, their own International Claim Form has no place on it to add a code number. If they needed a code to get this thing going, why would they not have a specific place, anywhere, requesting one or hundreds of codes for these procedures performed in a foreign country? I believe it was because they KNEW there were no codes in foreign cases. The estimated bill, thoroughly detailing the types of services planned was translated into English ("not acceptable" because it came from me, the patient. I was told I had to wait for BCBS to hire translator! I kid you not. ). The bill was paid in full prior to admission (BCBS: "This is not a bill.", for reasons I do not understand because that sure as heck was the $30 thousand bill I paid in full before they'd touch me.)Denials came citing that codes have to be included for each service provided(Me: Which codes? BCBS 'Your provider has to provide the codes". Me: The foreign provider doesn't use codes. BCBS "We need the codes". ) Finally, why would I have been partially reimbursed for the month in rehab which also had absolutely no codes on any form or bill? I was never reimbursed for the costs pertaining to the surgery, but I was partially reimbursed for the rehabilitation, no codes, that followed. Does that make any sense? No, it doesn't. Baffled-c
 
May 15, 2016
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#14
I am sorry that you have had such a rough time with this. I cannot answer why BC paid some and not others. I cannot explain how BC puts the onus on you to get these codes. You would ahve to ask them, but that would not get you any further in your goal to get paid. I tried to give a suggestion that I believed would have helped. I think in your case, you should look into hiring a health care advocate. This ideally would have been done 9 years ago. With a $30,000 bill, I think it would have been worth your investment to use a resource like this.
 
Oct 30, 2018
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#15
Thank you, woodworker, for your reply. Can you advise me as to where I can find a legitimate health care advocate? At his point, if it can still be done, and I pray it can before something else happens to suck up all my time, I would appreciate an advocate who could apply the right pressure to the right place. I am so tired of fighting and getting nowhere with these people. Many thanks.-c
 
May 15, 2016
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#16
I would google "health care advocate" and your zip code. That is the best way to get information today - from the web. As far as determining their "legitimacy" that would be the same due diligence as anyone else you hire - online reviews, better business bureau, etc. Good luck.
 
Oct 30, 2018
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#17
Does your insurance actually offer protection outside the US? Most in this country don’t offer that kind of coverage.
Yes, my policy allowed the coverage for the services, and that was confirmed in the two conversations I had with BCBS rep's prior to the surgery. "Just like an American hospital...", was the reply from one rep. I went in expecting that all would go well. Boom.
 
May 15, 2016
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#18
We have a Blue Cross/Blue Shield policy. (BC/BS is actually a "franchise" - they franchise the name to local independent non-profit companies in each state). On two separate occasions, my wife needed medical care in Europe (granted not as complicated as the OP with a $30,000 hospital bill). In each case I converted the written diagnosis to an ICD code, and the procedures to CPT codes (I can see how this would need an advocate if i was not in the medical field) and each time the bill was paid in full in a timely fashion. In fact I was surprised by how quickly and painlessly it was paid. Note we submitted the bill to the local franchise, not to some other international office. I don't think BC/BS is trying to give the OP a hard time; they just need a diagnosis code and a procedure code, and they have been consistent in saying that to the OP, and he has spent the past 9 years arguing with them apparently, which is not going to get him anywhere without those codes! The advice he got from his radiologist friend of 20 years that there aren't any codes is just silly - every procedure the radiologist performs and bills for has a Dx and Proc code.
 
Oct 30, 2018
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#19
I appreciate your input very much and the fact that you understand that a policy-holder would be wise to enlist the services of an advocate to submit a claim of this sort. As this work was done in Germany and I was told they don't use codes in Germany, I don't know if that would have worked and at the time, I was facing divorce, breast cancer treatments and surgery and my mother's paralysis, so I wasn't thinking straight at all and was mentally and physically overwhelmed.I depended on my insurance company which I had been paying premiums to for decades to know what to do. I was naive but I don't think I should be punished for it by them. I was not and am not in the medical field. Do you know the ICD code for a broken hip with necrosis?
 
Jun 30, 2017
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#20
I appreciate your input very much and the fact that you understand that a policy-holder would be wise to enlist the services of an advocate to submit a claim of this sort. As this work was done in Germany and I was told they don't use codes in Germany, I don't know if that would have worked and at the time, I was facing divorce, breast cancer treatments and surgery and my mother's paralysis, so I wasn't thinking straight at all and was mentally and physically overwhelmed.I depended on my insurance company which I had been paying premiums to for decades to know what to do. I was naive but I don't think I should be punished for it by them. I was not and am not in the medical field. Do you know the ICD code for a broken hip with necrosis?
2012 ICD-9-CM Diagnosis Code 733.42 : Aseptic necrosis of head and neck of femur. ICD-9-CM 733.42 is a billable medical code that can be used to indicate a diagnosis on a reimbursement claim, however, 733.42 should only be used for claims with a date of service on or before September 30, 2015.
2012 ICD-9-CM Diagnosis Code 733.42 : Aseptic necrosis of head ...

www.icd9data.com/2012/Volume1/710-739/730-739/733/733.42.htm
 
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