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

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May 15, 2016
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#21
You NEED a health advocate. Getting a diagnosis ICD-10 code will not be sufficient. The hospital bill will have to be broken down to specific procedures that will need to be coded with CPT codes. That is beyond the scope of this forum.
 
Likes: Neil Maley
Oct 30, 2018
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#22
You NEED a health advocate. Getting a diagnosis ICD-10 code will not be sufficient. The hospital bill will have to be broken down to specific procedures that will need to be coded with CPT codes. That is beyond the scope of this forum.
Of course. I agree. Thank you for your help and guidance. It is much appreciated.
 
Oct 30, 2018
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#23
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.
Dear jsn55,
Here is the narrative I have put together to add to the dfs.ny.gov website for complaints under their jurisdiction. I would appreciate any advice you would like to give and thank you for your kindness.
On October 16th, 2009, following a fall in Germany, I was advised to have urgent hip replacement surgery. Since the fall occurred in Germany, I had the surgery there in Bonn so as not to cause further, possibly permanent damage to my hip. I spent 11 days in hospital and four weeks in a rehabilitation center in the same city. Prior to surgery, I had twice contacted my hospital provider at the time, Blue Cross Blue Shield of New York, and was told the claim would go smoothly, “Just like in an American hospital.” but upon my return to NYC and submitting the claim to BCBS Blue Card International, the claim was rejected because I failed to indicate the medical (ICD) codes for each item claimed (Germany does not use these codes) and because I had failed to supply a bill. I supplied a copy of the bill three times. I was never reimbursed for the surgery part of the claim but I was reimbursed for the rehabilitation that followed it, which also had no codes and for which I supplied a copy of the bill, which was accepted. I fought BCBS and Emblem Health GHI for more than a year, when my 35-year marriage began to end in a protracted divorce process, I was diagnosed with breast cancer and underwent tumor-reducing treatments and a double mastectomy, and then my mother became partially paralyzed and succumbed to dementia. I was unable to continue fighting with insurance companies and had to take care of myself and my mother. This Spring I made a face-to-face visit with GHI (still my supplemental insurer) in lower Manhattan and was reimbursed over $6,000 due to the fact that the VP of customer service felt there was no reason to have denied the claim in the first place. She advised me to contact BCBS for their part. I would like to pursue my claim with BCBS and possibly resume additional follow-up with Emblem Health GHI. I have a large amount of paper files that I am willing to bring to a face-to-face meeting with BCBS if that is deemed necessary.
 

jsn55

Verified Member
Dec 26, 2014
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#24
This is fine. Way back in '09, did you speak to your insurer and inquire about the lack of billing codes in Germany? Did they offer any solution at that time, or subsequently? Your situation seems so simple to fix, but it's been going on all these years. I know that insurance companies ask for things one by one, and ask for them several times, but eventually they pay the claim. You really can't move forward with this without some professional assistance by a health advocate. There has to be a solution, but it will take very specialized expertise to obtain one.

For our other readers, this is an example of "concise facts":
Hip replacement in Bonn, Germany 10/16/09 after a fall. Eleven days in hospital and 4 weeks in rehab in Bonn. These two sentences state what this paragraph states:
"On October 16th, 2009, following a fall in Germany, I was advised to have urgent hip replacement surgery. Since the fall occurred in Germany, I had the surgery there in Bonn so as not to cause further, possibly permanent damage to my hip. I spent 11 days in hospital and four weeks in a rehabilitation center in the same city."

It's vital that your communications are easily understood by the reader in one read-through. If there is too much information, your complaint may be set aside for later review and never see the light of day again.

The easier your situation is to understand, the better response you will get.
 
Likes: ADM
Oct 30, 2018
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#25
This is fine. Way back in '09, did you speak to your insurer and inquire about the lack of billing codes in Germany? Did they offer any solution at that time, or subsequently? Your situation seems so simple to fix, but it's been going on all these years. I know that insurance companies ask for things one by one, and ask for them several times, but eventually they pay the claim. You really can't move forward with this without some professional assistance by a health advocate. There has to be a solution, but it will take very specialized expertise to obtain one.

For our other readers, this is an example of "concise facts":
Hip replacement in Bonn, Germany 10/16/09 after a fall. Eleven days in hospital and 4 weeks in rehab in Bonn. These two sentences state what this paragraph states:
"On October 16th, 2009, following a fall in Germany, I was advised to have urgent hip replacement surgery. Since the fall occurred in Germany, I had the surgery there in Bonn so as not to cause further, possibly permanent damage to my hip. I spent 11 days in hospital and four weeks in a rehabilitation center in the same city."

It's vital that your communications are easily understood by the reader in one read-through. If there is too much information, your complaint may be set aside for later review and never see the light of day again.

The easier your situation is to understand, the better response you will get.
Thank you for the advice. I not only spoke to them many times but wrote to them about this and the "missing" bill. I will condense my letter to the state agency and start looking for an advocate. Also, I don't understand why I was reimbursed for the rehab but not for the surgery that preceded the rehab. It's as though parts of the claim went to Virginia to die and other parts were processed to completion somewhere else.
Many thanks for the help. I appreciate it.