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denied authorizations submitted by surgeon
Thanks to florida blue, I have been discharged from my surgeon's office, because their two requests for surgery have been denied and they can't keep fighting. The surgeon's office said "florida blue continues to deny everyone with the same insurance". Florida blue better pray to god that something does not happen to a patient, due to their negligence!
The first authorization 10/10/17 was denied with stipulations:
1- updated mri
2- physical therapy or another conservative therapy, in which... I had the trial spinal stimulator july 2017
3- I was smoking
4- my bmi was too high
The second authorization was submitted 11/14/17 with updated compliance:
1- updated mri
2- physical therapy and proof of spinal stimulator trial (conservative therapy)
3-documented proof of quiiting smoking 10/11/17
4- documented proof of lowered bmi
Both authorizations by a very credible surgeon that has been voted the #1 surgeon several times. Both peer to peers have been denied also.
I have 2 rods in my back, I have been dealing with this for a year, I live in pain every day, I am not able to walk stores or any amount of distance without severe pain. I substituted a few times during the summer and cried in pain as I walked the children from the class to the cafeteria. I can't do art shows, theme parks, hold my grandchildren, or get on the floor to play with them.
Florida blue's decision baffles me and I will not give up! I will go as far as I can. This is happening to too many people.
This will be reported to every social media there is!
Florida blue denies all authorizations for surgery and surgeon's peer to peer twice! I will be contacting every social media outlet there is to let everyone know about florida blue!
Please help! I am disgusted and heart wrenched over the guidelines and protocol of florida blueinsurance company. I am also baffled that florida blue insurance company can deny a request by a doctor regarding a patient's care. The following is an explanation per our telephone conversation. My surgeon, dr. Devin datta's office put in a request to bcbs for me to have back surgery on 10/18/2017. On or about 10/11/2017, I was informed by dr. Datta's office that bcbs denied my surgery. I was also informed that every patient that has gone through their office with this insurance has been denied for some reason or another. Dr. Dattascheduled a peer to peer, which was also denied. I contacted bcbs myself several times before I was able to get answers. At first, I was told that it was approved, I was given a reference number, codes, and dates of service. After contacting dr. Datta'soffice back, they informed me that the codes and authorizations that were given were for the hardware that was going to be used in my surgery. After contacting bcbs again and asking for a supervisor, I was connected with jennifer trout. Jennifer told me that the surgery was denied due to: my bmi being a little too high, I was smoking cigarettes at the time, and I did not have an mri, physical therapy, or injections in the last 6 months. I explained to jennifer that I had back surgery in 2013 and 1 in 2014 and had 2 rods in my back already. Last year before my visit with dr. Datta, my neurologist ordered a ct myelogram, which is an extensive test showing results or damage around the hardware in my back and previous surgeries. It took me 5 months to get into dr. Datta's office. I had therapy last year before I went to dr. Datta and the ct myelogram.in july 2017, I had a spinal stimulator trial put in my spine with the hopes that it would work and I could avoid surgery. Spinal stimulator: a type of implantable neuromodulation device (Sometimes called a "pain pacemaker") that is used to send electrical signals to select areas of the spinal cord for the treatment of certain pain conditions. Scs is a consideration for people who have a pain condition that
Has not responded to more conservative therapy.
Unfortunately, it did not work. I have been out of work since last november, no income whatsoever, homeless (Staying at a friend's house for now), and I have $75 copays every time I go to therapy or surgeon. My help from people is running out.
In my last conversation with jennifer, she told me that the surgery was denied due to: my bmi being a little too high, I was smoking cigarettes at the time, and I did not have an mri, physical therapy, or injections in the last 6 months. I have complied with everything. I had an mri, my last cigarette was october 11, 2017, I have been to therapy a few times which is not helping, my bmi is lower, because the weight the doctor's office had was the weight I gave them 265lbs. I actually weigh 249.5 lbs at the present time. I also had the spinal stimulator trial, which would be considered another "conservative therapy" before surgery. I had an appointment with my primary doctor, so everything is documented. If I need to be tested for nicotine, I have no problem complying, but I continue to wear the nicotine patch.
Last week, my surgeon's office resubmitted a request with updated compliance for authorization for the same surgery on levels l2-l3 and l5-s1. The surgeon's office contacted me to inform me that florida blue is now approving l5-s1, but is denying surgery on level l2-l3. This morning, I contacted customer service once again, only to be told that they have more stipulations.
The surgeon's office said they have denied surgery for almost every patient on the same insurance. How can they get away with this?
Please help!
Sincerely,
Donna zerlin
D. O. B. 12/29/1967
[protected]
I need my plan to be updated with my newborn added so he can have surgery
I am having trouble getting an issue resolved with florida blue and my insurance plan being processed. I am an existing customer that tried to add a new born to my plan. This has been going on for over 1 month now and everyone tells me that they are waiting on another department to do something yet I have paid my premium, I have done everything you have asked and have spend hours just trying to get my new born added to my plan, but no one seems to care enough to get it done. Now my new born son needs surgery and I do not have coverage for him. I need help!
authorizations - see attached pictures
See attached pictures... Complaint previously sent
Please help! I am disgusted and heart wrenched over the guidelines and protocol of florida blue insurance company. I am also baffled that florida blue insurance company can deny a request by a doctor regarding a patient's care. The following is an explanation per our telephone conversation. My surgeon, dr. Devin datta's office put in a request to bcbs for me to have back surgery on 10/18/2017. On or about 10/11/2017, I was informed by dr. Datta's office that bcbs denied my surgery. I was also informed that every patient that has gone through their office with this insurance has been denied for some reason or another. Dr. Datta scheduled a peer to peer, which was also denied. I contacted bcbs myself several times before I was able to get answers. At first, I was told that it was approved, I was given a reference number, codes, and dates of service. After contacting dr. Datta's office back, they informed me that the codes and authorizations that were given were for the hardware that was going to be used in my surgery. After contacting bcbs again and asking for a supervisor, I was connected with jennifer trout. Jennifer told me that the surgery was denied due to: my bmi being a little too high, I was smoking cigarettes at the time, and I did not have an mri, physical therapy, or injections in the last 6 months. I explained to jennifer that I had back surgery in 2013 and 1 in 2014 and had 2 rods in my back already. Last year before my visit with dr. Datta, my neurologist ordered a ct myelogram, which is an extensive test showing results or damage around the hardware in my back and previous surgeries. It took me 5 months to get into dr. Datta's office. I had therapy last year before I went to dr. Datta and the ct myelogram.in july 2017, I had a spinal stimulator trial put in my spine with the hopes that it would work and I could avoid surgery. Spinal stimulator: a type of implantable neuromodulation device (sometimes called a "pain pacemaker") that is used to send electrical signals to select areas of the spinal cord for the treatment of certain pain conditions. Scs is a consideration for people who have a pain condition that
Has not responded to more conservative therapy.
Unfortunately, it did not work. I have been out of work since last november, no income whatsoever, homeless (staying at a friend's house for now), and I have $75 copays every time I go to therapy or surgeon. My help from people is running out.
In my last conversation with jennifer, she told me that the surgery was denied due to: my bmi being a little too high, I was smoking cigarettes at the time, and I did not have an mri, physical therapy, or injections in the last 6 months. I have complied with everything. I had an mri, my last cigarette was october 11, 2017, I have been to therapy a few times which is not helping, my bmi is lower, because the weight the doctor's office had was the weight I gave them 265lbs. I actually weigh 249.5 lbs at the present time. I also had the spinal stimulator trial, which would be considered another "conservative therapy" before surgery. I had an appointment with my primary doctor, so everything is documented. If I need to be tested for nicotine, I have no problem complying, but I continue to wear the nicotine patch.
Last week, my surgeon's office resubmitted a request with updated compliance for authorization for the same surgery on levels l2-l3 and l5-s1. The surgeon's office contacted me to inform me that florida blue is now approving l5-s1, but is denying surgery on level l2-l3. This morning, I contacted customer service once again, only to be told that they have more stipulations.
The surgeon's office said they have denied surgery for almost every patient on the same insurance. How can they get away with this?
Please help!
Sincerely,
Donna zerlin
D. O. B. 12/29/1967
[protected]
claim rejections
Hi my name is delia and I work for the woodruff institute in estero and naples area. I have been working in billing for almost 20yrs and the last two years have been the worst when it comes to getting claims paid by florida blue. We used to be able to appeal a claim and thing would get paid but in the past two years it has been very difficult because the language barrier between us and the person on the other end or the telephone. It is very difficult to understand the person who is on the other end of the phone because the english spoken is broken english. Besides not able to understand the person, claims are being rejected even with proof of timely filing. This getting out of hand and something needs to be done about this.
If your providers belong to the Florida Medical Association I would consider letting them know what is going on. Our own local medical association is awesome about helping practices with issues just like this. Florida Blue sounds worse than Humana. I hate dealing with Humana's customer service. Even when you tell them that what has nothing to do with your question, they make this sound (kind of like Hmpt) and keep right on talking. I think it should be a requirement that if an insurance company's call center is located in another country that they should have two years education on the American Medical System with the last year being done solely in English.
authorizations
Please help! I am disgusted and heart wrenched over the guidelines and protocol of florida blue insurance company. I am also baffled that florida blue insurance company can deny a request by a doctor regarding a patient's care. The following is an explanation per our telephone conversation. My surgeon, dr. Devin datta's office put in a request to bcbs for me to have back surgery on 10/18/2017. On or about 10/11/2017, I was informed by dr. Datta's office that bcbs denied my surgery. I was also informed that every patient that has gone through their office with this insurance has been denied for some reason or another. Dr. Datta scheduled a peer to peer, which was also denied. I contacted bcbs myself several times before I was able to get answers. At first, I was told that it was approved, I was given a reference number, codes, and dates of service. After contacting dr. Datta's office back, they informed me that the codes and authorizations that were given were for the hardware that was going to be used in my surgery. After contacting bcbs again and asking for a supervisor, I was connected with jennifer trout. Jennifer told me that the surgery was denied due to: my bmi being a little too high, I was smoking cigarettes at the time, and I did not have an mri, physical therapy, or injections in the last 6 months. I explained to jennifer that I had back surgery in 2013 and 1 in 2014 and had 2 rods in my back already. Last year before my visit with dr. Datta, my neurologist ordered a ct myelogram, which is an extensive test showing results or damage around the hardware in my back and previous surgeries. It took me 5 months to get into dr. Datta's office. I had therapy last year before I went to dr. Datta and the ct myelogram.in july 2017, I had a spinal stimulator trial put in my spine with the hopes that it would work and I could avoid surgery. Spinal stimulator: a type of implantable neuromodulation device (sometimes called a "pain pacemaker") that is used to send electrical signals to select areas of the spinal cord for the treatment of certain pain conditions. Scs is a consideration for people who have a pain condition that
Has not responded to more conservative therapy.
Unfortunately, it did not work. I have been out of work since last november, no income whatsoever, homeless (staying at a friend's house for now), and I have $75 copays every time I go to therapy or surgeon. My help from people is running out.
In my last conversation with jennifer, she told me that the surgery was denied due to: my bmi being a little too high, I was smoking cigarettes at the time, and I did not have an mri, physical therapy, or injections in the last 6 months. I have complied with everything. I had an mri, my last cigarette was october 11, 2017, I have been to therapy a few times which is not helping, my bmi is lower, because the weight the doctor's office had was the weight I gave them 265lbs. I actually weigh 249.5 lbs at the present time. I also had the spinal stimulator trial, which would be considered another "conservative therapy" before surgery. I had an appointment with my primary doctor, so everything is documented. If I need to be tested for nicotine, I have no problem complying, but I continue to wear the nicotine patch.
Last week, my surgeon's office resubmitted a request with updated compliance for authorization for the same surgery on levels l2-l3 and l5-s1. The surgeon's office contacted me to inform me that florida blue is now approving l5-s1, but is denying surgery on level l2-l3. This morning, I contacted customer service once again, only to be told that they have more stipulations.
The surgeon's office said they have denied surgery for almost every patient on the same insurance. How can they get away with this?
Please help!
If my surgery is not authorized, florida blue will be leaving me with no other choice, but to contact every media outlet, state representative, bbb, insurance commissioner, etc.
Sincerely,
Donna zerlin
D. O. B. 12/29/1967
[protected]
unable to get medical attention due to inactive insurance without previous notice or cause
I had a minor accident on my foot back in april. My toe was deformed and I was under a lot of pain. I found out my insurance was inactive when I went to seek medical attention. I called fl blue and I was told that they don't know how my insurance had become inactive. Later, a supervisor explained that my health insurance premium payments had been applied towards my dental insurance. That it wasn't my fault and he apologized for it. However, it took them about two weeks to reinstate my insurance. By that time I took care of my foot using home remedies, bought a foot brace, etc.
Today I went to seek medical attention for what I am sure to be an staph infection inside my nose. My nose is very swollen, red and i'm in a "lot, lot, lot" of pain. I was turned away at the urgent care center for, once again, inactive insurance and I don't have a clue why. I can't get an agent or any body from fl blue in order to fix this because they not open to help members on sundays. I have to wait until tomorrow.in the past it had taken me numerous calls, every time I call agents tell me a different story until I speak to a supervisor usually after waiting more than 30 minutes to talk to one. Also, in the past they have deactivated my insurance for prescriptions taken them four days to reinstate
Now, I am afraid that when I call tomorrow they same thing as before will happen and I will have to wait another two weeks. As you will probably know.. Staph infections are very dangerous and known to be life threatening.
Please help! I feel powerless, scared. Literally sick and tired.
This company has been a terrible nightmare for me this year
florida blue
10/05/2017 I called florida blue and I talked to a representative by the name of "hugo". I explained to him that I was trying to find a physician that accepted florida blue insurance for my son and also I wanted to make sure that are insurance was effective so that we would be covered since u just had payed the premium. So he found pediatric virdi located at midflorida pediatric. So he told me to call that the pediatric and schedule the appointment and give the the reference number he gave me and his name, and I asked him if he was sure my son can be seen the month of october and he said yes your son will be covered I said okay n we hung up.
So right after that I called mid florida pediatrics and scheduled the appointment for the 9th of october and also gave them the reference number and the number of the representative that helped me which was hugo. So when the 9th of october 2017 came around I took my son to the pediatric and I also gave them the reference number and hugos name as well. My son was seen and had got two vaccines. (reference number-1-[protected])
So october 19th I called florida blue to see if someone could find a physician for me who accepted my plan, I was on the phone with a representative named "teresa" she had told me that my coverage with florida blue didn't start until november 1st, and I said that it was weird because "hugo" told me my plan was effective and that it was okay for me to take my son to the pediatric this month and so thats why I did I told her. She asked for the reference number so that she could check hugos notes. He put in the notes that the system had and error and that my insurance wasn't effective until november 1st. I was so surprised because hugo did not tell me that when he talk to me, it seemed like hugo put that there was an error in the notes to cover his job. So teresa tried to connect me to a supervisor and nobody answered. So I hung up with her called back and spoke to a supervisor named "ariel" I told him the situation and I said to him I was very frustrated that his employee told me the wrong information. Ariel told he would review the call and call me back in 30 mins and also he sees that hugo was wrong than he would take care of the visit my son had on the 9th of october. So than I waited and waited for a call back, still did not get a call. So I called and got on the phone with a representative and she reached him and he told her to tell me that he was still reviewing the called that had took place on october 5 2017 with hugo and that he would call back, so I said okay and hung up and I got a call back from ariel the supervisor, he apologized for his employees
Actions and he admitted that hugo was wrong for telling me it was effective
But he said that he cannot cover my sons visit unfortunatley because theres no way he can. I told him it wasn't fair because if his employee seen that he made a mistake and said that it was effective than he should of reached back out to me and let me know but he didn't. So ariel said he couldn't do anything to cover me. He told me I could submit a complaint.
So I was very unhappy. Its not fair and I should not have to pay for this visit because and employee was dishonest!
My client number is h21586752983
refusal to pay for approved operation
On the day of my preapproved prostrate surgery (11/7/16) florida blue cancelled my health insurance plan (a/c# h17243911) without notifying me. I am now being called to pay the bill. They never wrote to me cancelling the policy (still haven’t), I have called them numerous times to fix this problem, to no avail, they are alleging that I was behind in payment, not true. I want the bill for the surgery at mt sinai hospital new york paid, including anesthetists etc.
florida blue hmo medicare
My 85 year old mother has florida blue hmo medicare insurance. It is the worst insurance ever. She has had pain for the last three months with back and hip problems. We took her to the emergency room sunday because she has been on very strong pain and can't really walk anymore and the medicine was no longer strong enough. It takes forever for referrals to be approved. Someone could die before this is approved. She could have her surgery tomorrow but it can't be approved for some reason. If something happens to her because of this someone will never here the end of this. Moral of this is never get florida blue hmo!
getting a flu shot, coverage.
I went to the walgreens-baptist center to get a flu shot. They stated they are out of stock with no eta. I walked 15 feet over to the walgreens pharmacy, they have flu shots in stock. They punched in my bcbs card and stated, they will not cover it from us. I drove over to the cvs minute clinic and they punched in all my info, bcbs will not cover a $40.00 dollar flu shot for you from here either. I called all walgreens-baptist centers here in town, out of stock, no eta. I pay $6000 dollars a year for bcbs health insurance with a $1500 dollar deductible... So why does it matter where I get a $40.00 dollar flu shot? Why will bcbs not cover my flu shot? I can only get a flu shot from one company for bcbs to cover. $40.00?
referral
My husband broke his hand, went to the emergency room on saturday and an emergency room doctor gave him a referrel for a specialist. He waited, in pain, until monday and was then told by bcbs that he would have to see his primary care doctor first, after he already had a referrel, and now the specialist won't see him until wednesday. So now that his bones have set, they will have to go in and rebreak them, more money for bcbs I guess, when it could have been looked at and fixed today instead of 3 days from now. Meanwhile, he is still in pain. Thought bcbs was a reputable company. Doesn't seem that way now. This is ridiculous!
blue medicare supp plan f
Blue cross collected monthly fees, never processed claims. Wrote and visited their local location several times. No action, no response that I could access.
Now sending me monthly bills, I guess, can't access them.
See letter to chairman:
Via email, facsimile and first class mail
Mr. Pj geraghty, chairman
Bc/bs florida
4800 deerwood campus parkway
Jacksonville, fl 32246
July 23, 2017
Chairman geraghty:
Signed up for your blue medicare supplement plan f, paid the premiums, up to and including april. Approximately $932.00.
You policy has not covered hospital or physician visits, I am paying out of pocket for all excess billing that humana didn’t pick up? Humana was last years carrier.
I have called several times, visited your port st lucie office several times (terrible personnel, useless and disgusting) and written several times to no avail. Can’t even log on to your system, doesn’t work.
Here is what I demand, refund any and all premiums I paid, discontinue the payment due letters, cancel my “account” and leave me alone.
Please advise, via writing only.
Signed by me...
florida blue and their reps
Florida blue reps. Get better training on reps. Listen in and get rid of the liars and rude ones. I wanted to do something that should not be difficult. Trying to change my pcp - I was told I had to use the "proper term" by the second rep. My primary care doctor. I changed the name of the doctor on the website. I didn't want to wait seven weeks to see someone. I have had to call or contact 3 reps. And it still is not done. The first, rudy, said it would be done immediately. When I questioned it he said at the latest... By the end of the day... It was not. The next monday I called and the rep would not give her name. She was rude and wanted me to learn the lingo and use it if she was going to help. Still not done. Now that I am a third way through the 7 weeks, I wonder if the company knows how the reps tell the callers anything and/or treat them poorly. I left 2 complaints with fb and no one so much as sent one of those bs e-mail and at least acknowledged an issue. Get better training on reps. Listen in and get rid of the liars and rude ones.
horrible customer service, get transgred and disconnected. very incompetent.
I agree 100%. Their customer service sucks! When you contact via social media, it is always the same auto generated reply to contact them via an email that is linked to their FB and Twitter pages. When someone finally decides to reply, they are usually not helpful, rude, incompetent, or provides empty promises. It is a total waste of time. Why do members have to continue escalating simple requests or issues because their customer service department could not care less about their members or well-being.
refund for insurance payment. member number vmdh18273224
I joined the florida blue select in january 2017. My member number was vmdh18273224 and my name is peter kizza. My address is 1907 sw 75th terrace. However I only paid the january membership fees. Sometime in april I realized that I did not pay the membership fees for february, march, and april. I was told that my insurance was cancelled and was not going to be reinstated. My mother rosie kizza who was very worried that I was not going to have insurance called on my behalf on april 25th. She was told by one of the managers that if she paid $1, 22.00 my insurance would be reinstated and would cover up to may. My mother went to campus credit union the following day and borrowed $1122.00. When she called to pay the money she was told that it was not an option. She was transferred to plan options and her phone call was dropped. She called again and this time the customer service person who got the phone call told her to pay the money and the insurance was not reinstated, the money will be refunded. I called the following day and I was told that they were not going to reinstate the insurance and the money was going to be refunded. It has been a night mare trying to get the refund and extremely frustrating. The case number is 1-[protected]. I have called several times and my mother has called several times as well. I stay on the phone for at least an hour and we are given all sorts of excuses. The whole of may and early june I was told that the check was sent but I never received it. When my mother talked to them she pleaded that whenever they mail another check to call her. She was willing to pay money so that it can b tracked. The manager promised to call her but never fulfilled his promise. I last talked to them on july 7th and I was told that another check was mailed on june 23 th. I still have not received the check as of today july 15th 2017. I really don't trust whatever they tell me on the phone. All I need is the money back. My mother had to borrow the money and she is currently paying interest for it. Plrase can someone facilitate sending the money back. Please call me at 352.328.5690 to discuss the topic further on how you are going to refund the money. Hoping someone who can help
billing
This is the third time there have been problems with my bill. I have never paid late, if anything, I have paid ahead. Yet, this month I get a bill for 1, 683.45 due july 1st. My monthly payment for my son and I is $561.15. So they are saying I haven't paid in three months. Yet I have proved that the money has been taken from my bank account. They have canceled my policy once already and now are threatening to do it again. I am a member of the marketplace, so there is a three month grace period, so I should have never been cancelled. I have had an agent inthe villages, fl helping me. I had to pay $1, 122 in order to have it reinstated in april. Because of all these problems, some of my sons pediatrician claims have been denied because it has looked as if he was not covered. I am furious. I have an 8 month old son who has to have shots. The pediatrician has gotten a letter from bcbs wanting them to refund the claims that have been paid. I am a hard working mother and I need reliable health care. I'm ready to obtain a lawyer. I have had to the take off of work at times to visit my bcbs agent to get help. I am having to do this again on monday because this issue has got to be handled asap. I have two doctors appointments this friday and I don't want to be denied coverage. I am paid up through june; this should not be happening. My member number is h14967813
My name is kjersta l hunteman
claim settlement for wellness visits
I have been to trying to get wellness visits in oct-nov 2016 settled without success since jan, 2017. Starting with 'incorrect billing codes' to 'unauthorized service' reasons, fl blue has continued to delay payments to provider for the last 5 months starting jan, 2017. I have finally filed official complaint to state of fl after being hood winked for months. I can say their claim settlement department is one of the most inept departments I have ever seen and their customer support lies as I have proof of that. I am looking at all avenues to report their mismanagement of claims. Please suggest.
health insurance
Four months I have been trying to get my premium straighten out. Blue cross has stopped paying my claims. I enrolled in the market place and received my premium notice. I have paid it every month and blue cross said it is correct. They are trying to charge me 130.00 dollars more then the premium from the market place. I'm on the fourth escalation from the market place to get this resolved. I have a complaint in to the fl health commission and fl attorney general. The attorney generals office has turned it over to consumer protection. I'm so aggravated everyone blames the other I cannot get a straight answer. So I have over $4500.00 in dr bills that are not paid.
podiatry associates of florida
I was cancelled by the above company florida blue, jacksonville, florida on august 31, 2015. I paid a huge bill back to them of over $2, 000.00. The lady in charge of the investigation was meredith geiger. She sent me the bill which I paid back in full to florida blue. Why am I now getting a bill from podiatry associates of florida formerly owed by podiatrist curtis bleau, who I understand now has retired. The date of service claimed is august 3. 2015. The amount due was $80.00 the account number is [protected]. I have never been to the jacksonville beach location. Dr bleau only had locations on northside foot & ankle clinic 1740 edgewood avenue w. Jacksonville, florida 32208. The phone number is [protected]. The other location is westside foot & ankle clinic 1824 blanding blvd. Jacksonviile, florida phone number is [protected]. This bill has been paid why would anyone wait two years later to send this bill. If I am bothered any more by florida blue, I will go to the governor of the state of florida about this. All my bills have been paid.
Leave me the hell alone.
Eva connors
[protected].
requesting peer to peer review of a claim.
My doctor and I have been trying for months to set up a peer to peer review of a denied claim and florida blue has made it impossible. I have made multiple phone calls, sent messages through the florida blue website, and had several chat sessions. They have not responded to any of the messages, none. The phone and chat responses are to have the doctor call the provider line. He has tried twice but it does not allow him to request the peer to peer. The automated system asks for date of service, and when he enters it, the systems responds that there is no claim for that date of service (actually there are 6) but it will not let him proceed, nor is there a way for him to speak with a person. My doctor says the claim was for a legitimate medical service and that if he could speak with a peer, he is sure they would agree. All we are trying to do is set up a peer to peer reviews, but the system will not allow it.
If the results of the peer to peer were not in my favor, then I could accept that. But florida blue not following there own policy and their customer service representatives being unable or unwilling to help find a way to set up the peer to peer is very poor. All we are asking for is a phone call for a peer to peer review and all we get is a dead end and the runaround.
Good for you, keep the pressure up, & make sure your facts are correct and true, it's the only way to get Florida Blue to change and accept their mistakes. They did it with me when they sent me a bill from a Doctor that Florida Blue paid nothing, Zero was paid, the Doctor expected me to pay the balance, but the Doctor or Florida Blue didn't know that there is a law signed into effect in April of 2016 which does not allow balance billing. I had to do my own research and in fact it's in their own policy which they missed.
It seems with Florida Blue a patient must do their own research, because the people you talk to on the phone do not have the correct knowledge or information, it's easier for them to say no to a patient, so don't take no for an answer if you feel you are correct, because most times you will be.
address change
I am trying to change my address for the last 7 month. it has been changed at the market place that long already, but it seams like nobody is competed enough to call the market place and have them confirm the change. I keep contacting customer service about it. Half the time I am getting emails saying, that they have not received a note from the market place about my change yet (they should just call them and confirm it) and the other half I don't get an answer at all. I am just wondering, if I already have a problem with such a minor thing, what would happen if there would be a major issue.
not happy
maren shaw
I meet criteria for Wegovy medication and yet am being denied coverage.
None wants to do business with this provider.
They have poor communication skills and no Doctors office anywhere near me want to accept this ins. They have an outdated data base of doctors that will accept it it, as most won't.
New Directions has failed to provide an SCA or Authorization despite promising to do so. It has been nearly 3 months. Fl Blue is required to provide continuity of care but New Directions has intentionally blocked provider from being able to bill due to no fault of the provider.
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Oh, I would also ask, in your case specifically how they determine that the hardware is medically necessary but the surgery to install what they have agreed is medically necessary isn't authorized. That is like a car manufacturer saying that the transmission on your car is covered under warranty but the labor to install it is not authorized. Dumb...
Hopefully this will help. When arguing with an insurance you have to know what they are looking for. Surprisingly, many offices don't think to look at the medical policies. Florida Blue's at General Medical Policy can be found at: http://mcgs.bcbsfl.com/. Then in the left hand column you want surgeries and then you want Lumbar Spinal Surgeries and it will tell you their criteria. It is stated in the policy that you have to have stopped using tobacco at least six weeks prior and you cannot be morbidly obese. They do not define morbid obesity though. Typically morbid obesity is a BMI of 40 or greater or a BMI of 35 or greater if you have other complicating health issues like diabetes, heart disease, etc. If your BMI falls under that then your provider needs to find out WHAT their definition of morbid obesity is. If FB is saying you are morbidly obese because your BMI is like 38 and you DON"T have a co-morbidity (like diabetes or heart disease) then your doctor needs to point out to them that by their own position statement for bariatric surgery they (FB) define morbid or severe obesity as BMI greater than 40 in patients without other co-morbid complications so by their own definition you cannot qualify as morbidly obese.
The medical policy lists all the various CPT codes and it will tell you which ones they consider "investigational" Investigational is a whole different thing to argue.
I don't think the spinal stimulator counts as "conservative" therapy in their books. The doctor needs to be specific when he does the PA. Either proof that you've done their required criteria or clinical reasons why you cannot. For example: Say 34 year old woman with a BMI of 36 with Type 2 diabetes needs spinal surgery. I would say something like: Spinal surgery is medically necessary for Ms. Doe. She has a three year history of spinal issues with previous spinal surgeries done in 2013 and 2014. Her condition is impacting her daily activities. She cannot sit for very long periods of time and therefore has been unable to work. She is currently unemployed and living with a friend. This condition has been on going since 2011. She previously tried treating with NSAIDS and physical therapy prior to her surgeries in 2011. I do not have documentation of that because it was through another provider but it is something her insurance required prior to surgery at that time as well. The pain she is under is making it difficult to control her diabetes. She is currently not a candidate for steroid treatment or NSAIDS because steroids would complicate her glucose control and NSAIDS could be damaging to her kidneys, particularly in the presence of her diabetes. Good glucose control is critical to her recovery. As far as her BMI is concerned, I appreciate that morbid obesity can hinder her ability to heal but we are talking about a difference of 1. Please provide me with the clinical data that shows that a BMI of 35 is going to vastly improve her surgical outcomes over a BMI of 36. The consequences of not doing surgery is far more detrimental.
That is just a very rough brief example of what you have to do. Either specifically meet or explain 0why you can't meet each thing they are looking for. t's kind of like a debate. If you don't meet their criteria you have to be able to refute their opinions with solid evidence. Hopefully that helps...