Grievance Victory!

I knew the day had come. On my way to pick up the mail at my PO box I was extremely nervous to receive a letter from Anthem Blue Cross. It had been 30 days since I filed a grievance with Anthem concerning my emergency larparscopic appendectomy I had in NYC on June 9. Apparently the surgeon they used for the surgery was "out of network" so I would have to pay for anything they deemed above "Usual, reasonable and customary". So I was slapped with an overage of $1200 and filed the grievance since it was so unfair. See my post here to read the entire background.

The letter I received on Friday stated, "Upon review of the above-mentioned claims we have found that services have been processed according to your in-network benefits. The provider of service, Dr. *****, is a participating provider. The claims were originally processed under your HMO group number and this provider does not participate in the HMO network. We have adjusted the claims to be processed under your PPO plan group number. We apologize for any inconvenience this may have caused."

This entire ordeal is so strange since I was told directly from an Anthem service rep that the surgeon was NOT in the PPO network and I would have to pay the overages. That is why I filed the grievance in the first place. Why was I told one thing and now this letter is reflecting the opposite? I guess I am not going to question this further. Frankly, I would like to keep the $1200 I would have had to pay. It's just a clear example of a severely screwed up health care system.

The ENTIRE TIME no one at Anthem Blue Cross could have simply looked up the surgeon's name in a fucking database and found out he was "IN NETWORK" according to my PPO plan??? This is the US health care system at its worst. Unproductive. Wasteful. Inefficient. Unsatisfactory. Note to President Obama, please fix this! I really hope a heath care bill can get passed in 2009. I already know that not everyone is going to be happy with this reform but this country needs something. There are too many people who have no insurance and then end up in the ER with a $28,000 bill and no way to pay it.

Filing Grievances with Insurance

I went into my Anthem Blue Cross account online today to check on the claims related to my emergency appendectomy that I had on June 9 in New York. They have already screwed up once since they posted all the claims to my OLD insurance account that I had at my former employer. I also had Anthem and my new member # is almost the same except for the prefix sequence. When I was in NYC I told the hospital to use my new insurance. I even limped my way went down to the billing dept after I was discharged to MAKE SURE they had all the correct info. Still, it was charged to my old insurance. Great job! I called today and Anthem is going to post the charges to my new insurance acct that went into effect on June 1. So at least that issue will be taken care of.

Unfortunately there was another serious billing issue I discovered. I was reviewing the claims online because there is a separate claim for each doctor. For example, the anesthesiologist charges a separate fee. The radiologist charges a separate fee, etc, etc. There were 3 separate charges for the surgeon who performed my appendectomy. Anthem will not pay the entire claim because he was an "out of network" doctor. Although it has not been billed yet and it says "pending" on the online claim, my possible portion of the bill will be $1666!

How would I have known the doctor was out of network? Oh, I guess I forgot to ask while drugged up laying naked on the operating table, "Before you slice open my abdomen, is the surgeon in my network?" The hospital did what they needed to go to get my surgery completed and they had to call in a specialist. I understand that completely. This was not a planned operation and I HAD NO CHOICE IN THE MATTER. That's what an ER is all about - the unexpected. I didn't PLAN to have my appendix almost burst while in NYC. Now, this argument hopefully, will save me $1666 in charges.

The Anthem rep, who was amazingly helpful, told me that he hears these cases all the time. HE told me he would file a grievance for me. I will know in 30 days what the judgment will be. He says they have an entire dept at Anthem dedicated to researching grievances and negotiating with the various doctors who charge the exorbitant fees.

What I don't understand is why I may be responsible for charges that could have been prevented. It's not fair and I actually have insurance! What is wrong with this picture? Should I have refused the operation and risked my life? What about all the people who don't even have insurance? Here I am, possibly having to pay $1666 for an operation that, according to my insurance, should have only cost $250. That's right, according to my benefit coverage, if admitted to a hospital I only have to pay a $250 co-pay and all physician and surgical services are covered at 100%. That is for in-network though. Could the hospital used one of their own doctors to do this surgery? I have no idea. Again, I had no control over the situation and I wasn't making the decisions. The decisions were being made FOR ME. I was out of the loop and shouldn't pay the price. I was traveling on business and had no idea this was going to happen.

It seems like I should have a great case to escape the charges. I hope I do. Although I have no idea what the Grievance Dept at Anthem does exactly, the rep told me the rep told me they deal with these situations all the time with out of network doctors charging INSANELY high fees. Oh I almost forgot, one of his fees for "ER services" cost $1125. I only remember seeing him one time just before I went up to the operating room. All he said was "Hi. I'll be performing your appendectomy tonight." That was it. What exactly cost $1125? He never touched me in the ER. He was in street clothes and looked like he just got there. Also, the day after the surgery he came to see me for about 3 min and looked at the bandages. That cost was $595 and my portion is $350! Whatever. I really hope Obama can get universal health care passed so everything is regulated. This is out of control.