AboutTricia Expertise Has your medical insurance company denied your claim and refuses to pay? Have
you received a pre-authorization and still your insurance company
refuses to pay? How can you get your insurance company to reverse a
denied claim? How do you get a provider to waive your copayment if you
are financially unable to pay? Can a provider sue you for a unpaid bill and
will they? Can a provider send me to a collection agency for a medical bill?
If my insurance company does not pay, am I responsible? If you have these questions or others on why your insurance company is not paying your bills, I can help. I can give you "tricks of the trade" to get your insurance company to pay.
I have limited knowledge on Medicare and Medicaid and that is not my expertise. Each state is very different regarding Medicare and Medicaid so you need to review their website when you have questions. So please no Medicare or Medicaid questions!!
Experience In the medical field for over 20 years spending majority of time in the collections aspect.
Your answers and suggestions are great. Thank you in advance for your help. My question is the following -
I am a NJ resident and have a traditional plan PPO with NJ Blue Cross Blue Shield
I required a special surgery in San Diego, CA in September 2008. The hospital and doctors are in-network with Blue Cross of California. An insurance analyst for the CA hospital handled all the pre-authorizations with NJ BCBS and any initial insurance work that was needed.
To date, all 56 doctor claims have been processed and the EOB’s match the bills. Every line item, to the penny.
To date, 4 hospital claims and EOB’s have been processed. These EOB’s generally have 15-20 line items. All line items ( except for one ) have been processed correctly with the contracted rates.
All the other lines listed on that EOB had an allowed amount that was 15.4% of the billed amount.
There are no message codes or indicators on the EOB other than the standard one - 4007, if you have another health plan, file a claim with that plan. ( I do not have a secondary plan ).
The California hospital says I owe them $2,948 because the above line is a non – covered charge. They tell me that is also what they have been told by Calif Blue Shield. I have been told I am not allowed to call Calif Blue Shield because I am a NJ BCBS member.
NJ BCBS tells me the EOB is a legal doc, the provider is an in-network provider, I do not owe anything. They tell me Calif Blue Shield handled all the processing of the numbers as the local insurance company to the provider. This line was probably “included” with the allowances from another line. NJ BCBS claims that Calif Blue Shield called the provider and the provider was told no patient responsibility. The calif provider is also "not allowed" to call NJ BCBS because they are a CA provider.
I have asked the hospital for an itemized statement, have not received it yet.
Am I responsible for the $2,948 ? I thought if a claim or line item was denied, there is a code and some explanation, and an amount in the subscriber responsibility column ?
Thanks for your help - Edward
Answer Hi Edward!
Usually if a service/item is considered non covered the patient is liable, however if your local plan/policy is stating you are not then get them to put that you are not liable for this non covered charge and send that letter to BC of CA.
Blue Cross's are very difficult at times to figure out----the more they confuse you the better chance someone will pay when they should not.
