I'm trying to make sense of an updated Explanation of Benefits from BlueCross BlueShield, I just got for my first BHR surgery Jan 23rd, 2012. The updated EOB is dated 2/04/2013. I'm going to be on the phone with BCBS first thing tomorrow, but I'm looking for feedback from anyone who may have encountered something similar.

An explanation at the top reads:

"The claim for this patient was reviewed based on the additional information received. The following shows how this claim was adjusted."

However, this claim was already paid more than a year ago in the amount of roughly $29,000. What it now shows, is that all items connected to my hospital stay are *not* covered. Under the list of *not covered* items, there is a code next to each one labeled (1).

That (1) code corresponds with the following item in a legend at the bottom of the EOB:

"This expense/service is not covered under the terms and conditions of your Health Care Plan. No payment can be made."

Under "Amount you may owe provider" is $0.00.

Surgery was pre-authorized, and BCBS does cover joint arthroplasty, so WTF? Is BCBS going to demand it's money back from Swedish Orthopedic? Demand money from me? And what about my more recent claim for BHR surgery which has been paid?

Anybody ever encounter anything like this before?

Bizarre. They are adjusting it, but you owe nothing.

I've never run across this; let us know what happens, the mysterious ways of the medical bureaucracy are truly astounding.

Rob,

My wife was an ombudsman for a large hospital system for many years, and has helped thousands of people over the years.  Her impression is since it is aleady paid, that this is a typical screw up in the billing which you should be able to argue in your favor. 

The billing screw ups with my HR's, had to be sorted out as well, even with the secondary coverage provided under her policy by a subsidiary of the hospital itself, were fubared both times, by both insurers.  Although she hates having to get involved because of how dumb the whole thing can be, once she does, they usually wish they would have done it right the first time  :).

The aggravation is no small thing for sure, hope you cut through the BS soon.

Dan

Hello Baby Barista -

Don't know if you'll see this tonight, but try not to lose any sleep over it!

I went into my BHR adventure in October of 2011 with both the hospital and Doctors office aware I was covered by two different BCBS policies.  Maybe two months after the procedure I received an "EOB/This Is Not A Bill" from one BCBS informing me that $93,000 and some change was my responsibility...Choke!  Not too long after that another "EOB/This Is Not A Bill" from the other BCBS stating the same thing, but they both seem to have worked it out amongst themselves as I have not heard much since other than getting penalized for not getting preapproved.  That penalty was supposed to be for $500.00, but I have not seen a bill and there are no collection agencies knocking at my door almost a year and a half later.

Hope you get it sorted out to your satisfaction!

Bruce

My insurance company refused to pay for a follow up after I fractured originally saying that they only covered Chronic conditions not check ups. But I have since spoken to a sensible human being at the same company and he accepted that because I fractured I needed the checkup and Xrays.

I think you just have to speak to the right people.

So I still don't really know what's going on. What I do know, is that it's related to Swedish Orthopedic withdrawing the previous claim and submitting a new one. I can't get my way through the proper channels to find out why. Could it be I'm getting a two-for-one discount? Who knows... I'm not losing sleep over it. I'll update when I learn more.

Hopefully it was an error on the biller's part.  I used to run a billing dept for a D & T and when I first inherited that dept they could not tell me what was already billed and what wasn't and the only way to know for sure was to have my staff rebill everything.

Sometimes things will get rebilled and then if previously paid by the insurance carrier it will subsequently get denied when the rebilling occurs..  Do you have the original EOB from when it was originally paid? 

Another thought is whether you had to have a preauthorization for the procedure.  Many people get into trouble because the doc's scheduler did not get that preauth.

I am very interested to hear how this turns out.

I hope it is just an internal problem on the billing end.

Kim