My question involves insurance law for the state of: Texas
Before surgery, wife's surgeon had a medical supply company send her a Plasma Flow leg compression device without our knowledge. The medical supply company called my wife and told her they would send it and all cost would be paid by insurance. So she said ok without my knowledge.
Supply company, which was in-network, filed claim which was denied because they did not pre-certify it. EOB said I had zero responsibility. Claim amount was $5000. I see this on an internet medical supply web site for $143 and on Ebay new for $70. Then Company#2, which is probably the distributor for Company#1, decides to file a claim for $6000. #2 is out-of-network, so claim is denied for same reason, but because out-of-network EOB says I may be responsible for the $6000.
I call BCBS and tell them claim#2 should be denied because it is a duplicate of claim#1. They did not seem to agree on that. Then I tell them I never received any item from Company#2, so they make a claim adjustment which the person said should make me not responsible. But now I get EOB #3, and it also says I may be responsible for $6000. It was denied due to "your plan covers rental equipment up to purchase price. Because the rental charges exceed the purchase price, or the purchase price has been paid on a previous claim, no further payment can be made".
I do have an option for appeal to TDI (Texas Department of Insurance) as I am a state employee and their Health Select is covered by TDI. Do I have other options? Of course, I will be calling Blue Cross to complain again. I also see they have a Fraud Hotline number. Should I try to call this fraud? Seems like going up the supply chain until you can find an out of network vendor should be illegal?
Before surgery, wife's surgeon had a medical supply company send her a Plasma Flow leg compression device without our knowledge. The medical supply company called my wife and told her they would send it and all cost would be paid by insurance. So she said ok without my knowledge.
Supply company, which was in-network, filed claim which was denied because they did not pre-certify it. EOB said I had zero responsibility. Claim amount was $5000. I see this on an internet medical supply web site for $143 and on Ebay new for $70. Then Company#2, which is probably the distributor for Company#1, decides to file a claim for $6000. #2 is out-of-network, so claim is denied for same reason, but because out-of-network EOB says I may be responsible for the $6000.
I call BCBS and tell them claim#2 should be denied because it is a duplicate of claim#1. They did not seem to agree on that. Then I tell them I never received any item from Company#2, so they make a claim adjustment which the person said should make me not responsible. But now I get EOB #3, and it also says I may be responsible for $6000. It was denied due to "your plan covers rental equipment up to purchase price. Because the rental charges exceed the purchase price, or the purchase price has been paid on a previous claim, no further payment can be made".
I do have an option for appeal to TDI (Texas Department of Insurance) as I am a state employee and their Health Select is covered by TDI. Do I have other options? Of course, I will be calling Blue Cross to complain again. I also see they have a Fraud Hotline number. Should I try to call this fraud? Seems like going up the supply chain until you can find an out of network vendor should be illegal?
Health Insurance: How Much Overcharging to Be Considered Fraud / Illegal
Aucun commentaire:
Enregistrer un commentaire