Any recourse/assistance available?

[Amanda81]

This is confusing, so try to keep up

On 11/12/2012 my mom had a Complete ALS Evaluation (lab panel) done by Athena Diagnostics, ordered by her local neurologist after he made the diagnosis of ALS, but before she saw a specialist in St. Louis who made the official diagnosis.

At the time of the test, she had Blue Cross Blue Sheild as her primary and only insurance.

After the official diagnosis in St. Louis, she applied for and was approved for Medicare. They back-dated Part A to 8/1/12 and gave us the option to pay the premium for Part B. We opted not to pay because we didn't see the need, so Part B was not effective until 2/1/13.

After paying the claim in full, but sending it to the neurologist instead of Athena Diagnostics, BCBS has decided they don't owe the full amount of the lab test, they only owe a portion (10%) and we need to bill Medicare. After explaining that Medicare wasn't active, they stated that she was *eligible* she just chose not to accept the coverage, so they're still not going to pay it in full.

This test was $5895 and BCBS is only paying $589.51. Medicare isn't paying anything b/c she didn't have Part B at the time. So my mom is stuck with a bill for over $5,000.

The test was never explained to us by the doctor. It only detects 75% of familial ALS and 15% of other ALS. So the test was pointless anyway. But we live in a society where we are taught to trust our medical professionals. She had the blood work done just like she had the MRI done to rule out other things before we settled on the diagnosis of ALS.

Is there ANYTHING we can do? Shouldn't the doctor have explained the test to us? And the cost of it? I know it is ultimately our responsibility to be informed and ask questions, but this is a hard pill to swallow. Any suggestions would be appreciated.

 

[vickim]

Do I understand this right, BCBS paid the dr and not the lab? If I do understand right why would the dr keep the payment? You should see if you can get the money from the dr and send it to the lab.

 

[Amanda81]

The Dr refunded it to BCBS b/c they thought it was an interest payment. I called BCBS b/c my mom received the bill from Athena for the full amount. It was during the search for the money that BCBS decided they didn't owe the full amount because she was eligible for Medicare at the time of the service.

 

[Nikki J]

There is a way to appeal any coverage decision the mechanism to do so will be in the Blue cross insurance documents. A lot of work but it is a lot of money

 

[old dog]

In another thread, (unfortunately I don't remember the title) a lawyer who is also a PALS offered to help PALS with these kinds of issues. If anyone remembers his name or the thread title, you might ask his advice.

Personally, I have never agreed to a procedure until I have some idea of what my out-of-pocket cost will be. My second neurologist wanted me to have genetic testing through Athena Diagnostics. I learned that Medicare would not pay anything on this. I could have ended up with a bill of approximately $24,000.

I wish you luck in resolving this problem. Your mom has enough to deal with without adding financial stress.

 

[Amanda81]

It is just one of those things where I want to blame someone else, but I know we should have asked more questions and gave a little more thought. But how can you at a time like that!? I work in an ER and I never imagined one little lab test could cost over $5000 out of pocket. Just makes me want to cry, and it's not even my money!

 

[old dog]

Don't beat yourself up over this. The only reason I had a clue about the potential expense of genetic testing is the neuro did tell me the cost might be high, so I knew to check into it. I was thinking in terms of hundreds of $ rather than thousands. I had no idea any lab test could cost so much!

 

[paul71]

I had an issue with a skin biopsy. An in-network doctor sent a test to an out of network lab. My insurance tried sticking me for a $2000 bill. Believe it or not, the insurance company (specifically the woman in customer service) was very helpful when I wrote my appeal. She was just a regular working stiff like me and was sympathetic to me. They deal with problems with their own insurance too. Maybe you could get lucky like I did if you call BCBS customer service.

The next time I had a biopsy, I taped the appointment on my cell phone. I explained that I didn't want any specimen sent to an out of network lab. If there are problems with insurance, I have my recording of the appointment as back up.

 

[Nighthawk]

Don't beat yourself up over this. The only reason I had a clue about the potential expense of genetic testing is the neuro did tell me the cost might be high, so I knew to check into it. I was thinking in terms of hundreds of $ rather than thousands. I had no idea any lab test could cost so much!

If you don't have the disease but FALS runs in your family, makes sense (as long as you have enough money to burn) to spend some $$$ and get yourself tested.
But, for a person already suffering from the disease there are other priorities like wheelchairs, walkers, home modifications, drugs, etc. it wouldn't make sense to throw away thousands ($$$) that you may need for something much more important.

 

[Barbie]

I would definitely dispute the refusal by BCBS with them, then if they still refuse I think I would at least talk with a lawyer to see what your options are.

 

[Katie C]

I agree with Barbie.. do some research and find yourself a local attorney used to working with medicare payment issue. At least get a consultation.

 

[Amanda81]

Sometimes, crying does help After a particularly frustrating day of conversations with people who would not help me at all, I lost my wits and sobbed to the Social Security lady. She called me back the next day and said she had spoken with her manager and they drafted a letter to some department that handled backdating effective dates. It was very well written (she read it to me) and explained our situation perfectly and factually. She said her manager would meet with the manager of that department and discuss it further after the letter was sent. A few days later someone called to advise that a bill would go out for the premium due for Medicare Part B from 8/1/12-2/1/13. We just need to pay it and the coverage would be backdated. Yay! What a relief! This was a nightmare! Lesson learned... ask questions, read fine print, think things through before making decisions. It's just easier said than done when more pressing issues are at hand. :-/

 

[Barbie]

Good for you Amanda! Good people know when the crying is for real and understand. I have done it a few times myself when I could not take any more. thank goodness that woman saw she needed to help you!

B