Posted by pedals on December 22, 2009 at 14:15:17:
After a long battle with BS, BS reimbursed my MMA surgeon’s fee using the billed amount, not the “customary” amount, as the basis for payment. The surgeon was not a preferred provider. Ultimately, BS agreed that they had no preferred providers in my area who do the procedure.Prior to the surgery, BS approved the procedure as being medically necessary, but would not commit to the amount they would reimburse until the actual procedure was performed. They gave me the names of three ENTs in my area who they claimed performed the procedure to ensure that I found a network provider – none of these physicians performed the MMA. After the procedure was performed, BS reimbursed roughly 8% of the billed amount.
I wrote multiple appeal letters to BS. The basis for the appeal was that there were no preferred providers in my area that perform the procedure. Based on the responses from BS, it was clear that they did not read any of the letters I sent. Each response from BS said I had the option to appeal to my state’s insurance board. After receiving each denial, I wrote another appeal letter and had multiple conversations with a representative in the grievance department. The final denial included a list of preferred physicians that BS claimed preformed the MMA. I called each physician – each one referred me to the surgeon who actually performed the procedure. My final letter to BS simply stated that their preferred providers referred me to the physician who performed the procedure.
I share my story to encourage others to be persistent with their own appeals.
Good luck!!!
- Re: BS Success Captin Cannuck 08:32 12/27/09 (0)