AboutMichael Higgins Expertise All questions pertaining to health insurance, whether group, individual/family, student, child-only, COBRA, HIPAA, Portability, dental. No expert knowledge in areas such as life insurance, disability, workman's compensation, auto, etc.
Experience 27 years as owner of health insurance agency, primarily dealing with Blue Cross Blue Shield of Arizona.
Education/Credentials College, Business Administration.
Question Please be advised and for the record I am disputing a claim with Great Neck
Stand-up MRI in the amount of $1520.00. On April 18, 2009 I had an MRI of
the lower back taken at Great Neck Stand-Up MRI. It was my understanding
prior to my scheduled appointment that Great Neck MRI accepts my
insurance carrier Blue Cross Blue Shield (BC/BS). My insurance card is current
and indicates all the necessary information and had this verified by the facility
one week prior to my appointment.
As it turns out on Friday, May 22nd I found out that BC/BS had denied the
claim because I had gone out of network. BC/BS informed me that no one
from the MRI facility had contacted them to see if my coverage would be
accepted.
Please know that I would have never gone out of network for this MRI
especially since there are 20 other MRI facilities in the Great Neck area. My
referring Dr. Stuart Hirshorn’s office let me know that I did not need any pre-
certification for an MRI and had given me a list of local MRI centers for me to
call for an appointment.
I have pleaded with BC/BS to allow some consideration in this matter but
there is nothing that they can do. Even though this was a medical emergency
the responsibility should be with the MRI facility in checking with BC/BS to
make sure that BC/BS would pay for the aforementioned MRI.
In conclusion, I cannot understand why the MRI facility would service me
without having a solid confirmation from my insurance carrier. I believe that
someone at the facility has made a terrible mistake and now there is this
large outstanding bill. I am currently in the process of seeing what my rights
are and hope that this situation can be handled in a respectful way. There
has been negligence in Great Neck MRI’s handling this matter and the lack of
disclosure prior to my procedure. As professionals in this field they should
have done their homework. What recourse do I have ?
Answer Hello Ralph:
You have proven, through the words that you have written, an understanding that the first rule in a dispute of this sort is to communicate your position in a professional, clear manner. Continue to do so when dealing with BCBS in your state, and the MRI provider, and it will pay off.
I'm handling a very similar situation here in Arizona for a client. Blue Cross of AZ. is investigating the claim as we speak. You have the right to petition your local BCBS for reconsideration of the claim. Each BCBS is separately owned/operated, and some are for-profit, others not. But they all abide by a standard set of rules and mission. To do no harm, and act in the best interest of the member is always a priority.
As a medical emergency this claim should have been processed and paid no matter the type of policy you have, i.e., HMO or PPO.
Let me have a little more information. What type of plan do you have, the plan name, is it a group policy or individual, what state do you reside and which BCBS are you dealing with. Possibly on Monday I can ask an upper management member at the local BCBS if they know someone in your state to look into this. Let me stress that I do not, in any way, doubt what you have said. That said, if everything you have stated if factual and accurate, I can't imagine how you will be held responsible for this claim, (other than any deductible and co-insurance that may apply.)
Lastly, for clarification, I am not an employee of BCBSAZ. By choice I represent them exclusively as a broker, and have done so for 29 years.
