June 11, 2007

Blue Cross Blue Shield Chronicles: Blue Distinction, Not

A few weeks ago, I posted an account of my trials and tribulations with Blue Cross Blue Shield Horizon of New Jersey. Well now it is high time for an update, an update I think readers of this blog will be interested in because it tells a fascinating story about the Internet, blogging, and perhaps new uses of Google Alerts.

My goal in writing the post was to inform readers of their options when faced with problems caused by their health insurance company. Well, I had no idea a response would arrive from Blue Cross Blue Shield, and so quickly. For within 2 hours of posting my blog entry, the Public Relations Director of Blue Cross Blue Shield of NJ wrote me an email, which basically said that he “came across my blog posting” and was offering his assistance.

Needles to say, I was shocked. After months of getting some of the worst customer service I have ever received (when on the phone with Blue Cross, I always felt like I was talking to smarmy collection agency reps), I get an email from upper-level management, offering his assistance.

At first, I thought some of my geek readers were playing a practical joke on me. While it seemed plausible that Blue Cross monitors links to their site, and probably do so with Google Alerts, I had a harder time believing that the Director of Public Relations would fire off an email to me, directly.

Naturally, following the arrival of his message in my inbox, a small glimmer of hope flickered, especially after he had someone from the Appeals Department contact me. And this small intervention had a large noticeable effect: decent and transparent customer service became a reality, for the very first time. Instead of interactions that were opaque and frustrating, I finally had ones that were crystal clear and intelligible.

According to the main Blue Cross Blue Shield Web Site, they pride themselves on “Blue Distinction:”

“Blue DistinctionSM is the Blue Cross and Blue Shield companies’ nationwide program that will create an unprecedented level of transparency with two goals: engaging consumers to enable more informed healthcare decisions and collaborating with providers to improve quality outcomes and affordability.”

The contrast of my service before and after having the Public Relations director contact me speaks volumes to the actual nature of “Blue Distinction” as it pertains to BCBS of NJ. For most of my interactions with Blue Cross Blue Shield, I encountered an unprecedented level of opaqueness and frustration until there was intervention from high-above.

I actually appreciated the service I received and saw it as a laudable move. Unfortunately, the outcome has been far from my liking. I recently got word they are not paying up for any of the dermatological services. So perhaps the fact that a PR person contacted me was significant because in the end, it has panned out as a typical PR move: all gloss and lacking substance.

What now? I am moving to an internal BCBS appeal process and if that does not work, I will move on to small claims court in NYC and perhaps a more organized web campaign. In the mean time I have basically have decided to blog about the process so look out for future updates!


  1. Wow, what a saga! I can’t believe that they have the audacity to claim that this is a pre-existing condition. Its like they are trying to redefine reality to suit their needs.

    Comment by micah — June 11, 2007 @ 9:50 am

  2. Wild. I recently blogged about my frustrations with Blue Cross myself when it appeared they had no intention to compensate me for three days in the hospital (for some reason the original receipts weren’t enough; they must think people stay in the hospital for fun or something). About a week later, their (horrible) website showed (with no explanation) a refund. So maybe they’re like the rest of us, Googling and Technoratiing for themselves. I took down my nasty post, but I’m still jealous of people who have different, less hassle-filled plans.

    Comment by Rod — June 11, 2007 @ 11:18 am

  3. Goodness! What a hassle! :(

    Comment by Simon Law — June 11, 2007 @ 11:22 am

  4. How does a mole constitute a pre-existing condition … under that logic would a masectomy not be covered for similar reasons? madness.

    Comment by Yari — June 11, 2007 @ 12:30 pm

  5. I am amazed at this Biella. I am in the process of shopping for health insurance for myself and will have to reconsider BCBS. Thanks for posting.

    Comment by Alex — June 11, 2007 @ 12:54 pm

  6. Unfair pre-existing clauses like this really hurt a lot of people. At the very least, the insurance company should have informed you of what they specifically aren’t going to cover before you signed up instead of pulling it on you after the fact. And like Yari says, just because a possible symptom shows up and is totally normal in previous checkups, how does that possibly qualify as a condition? If that’s the case, you may as well not get checkups period. Further, the math that the insurance company is using in this situation is screwing them as well — it’s to their advantage to pay for cases like this that essentially fall under preventative medicine.

    As a community and individuals, we have a lot of ability to fight this. You’ve done insurance activism before at the University of Chicago. We have a lot of media contacts in the blogosphere, as well as the mainstream press. We have the coders to start cranking out the websites. We can and should organize get up and organize and push back against these predatory insurance models.

    Comment by Praveen Sinha — June 11, 2007 @ 1:32 pm

  7. Also, when I next sign up for health insurance, I’m definately going to be tenacious when looking at their coverage for conditions. One thing that would also definately help in terms of organized consumer resistance is having comparative plans that explain to people in plain language what the insurance companies are going to cover, and what people’s REAL options are in getting the treatment they need.

    Comment by Praveen Sinha — June 11, 2007 @ 1:34 pm

  8. [...] say feigning incompetence because, a few days ago, something happened that caused a complete change in the way BCBS handles Biella’s case: she blogged about it. [...]

    Pingback by Health Insurance, CRM, Google Alerts, and Social Justice « Nonconfigurational — June 11, 2007 @ 6:08 pm

  9. And this was why I was perfectly happy not having health insurance. When I was an employee, I had lots of problems getting various insurance companies to pay for simple doctor visits, medications, etc (and I never even had any serious medical problems!)

    Working as a contractor, I was fine paying my own way for any medical problems that came up. Massachusetts now *requires* that everyone have health insurance, so now I have to give $150 per month to some scummy insurance company so that they can jerk me around when I actually need to go to the doctor… Sigh.

    Comment by Andres Salomon — June 12, 2007 @ 8:28 am

  10. [...] Well, within two hours of making that first blog post, she got a call from the Director of Public Relations for Blue Cross Blue Shield of NJ. He “came across her blog posting” and wanted to see what he could do to assist. This is all described in her second blog post. [...]

    Pingback by rants.org » Blog Archive » Embarrassment-based health care. — June 12, 2007 @ 9:11 am

  11. [...] « Blue Cross Blue Shield Chronicles: Blue Distinction, Not –  [...]

    Pingback by Interprete » ? I need a title — June 12, 2007 @ 1:56 pm

  12. I am about to change jobs to a job that offers Blue Cross Blue Shield. I’m a little concerned. But if they follow the law, I shouldn’t be. I have a mild case of Crohn’s. And acid reflux. I take Nexium every day. “Pre-existing condition” you say, but I’ve had coverage for over 5 years and was diagnosed after that coverage started. I will have a 30-day waiting period for BCBS once I start my new job. State law in MO says a break of less than 63 days is still considered continuous coverage. I really hope they won’t try and give me the run-around on this.

    Comment by Gabrielle — June 29, 2007 @ 1:15 pm

  13. Gabrielle

    You should be fine as you are not without insurance for more than 3 months. But alas, you may have other issues given how these companies like to deny basic service.

    But BCBS differs state to state so I just hope that in your case, it works out well!!

    Comment by Biella — July 1, 2007 @ 6:44 am

  14. First I am glad I found this website. Thanks for providing a forum and communication means for victims of Blue Shield.

    I too got my share of frustration in dealing with Blue Shield California. At my current job I don’t have much of a choice in terms of health care insurance. I ended with Blue Shield HMO. It’s turned out to be a painful mistake!
    I’ve referred to a specialist by my primary care physician (PCP) but I was told the wait was over 8 weeks and nothing I could do about it. Through this process I learned that Blue Shield sub-contracts to several more layers of medical groups, which dictate how I would be treated and where I could be treated. So, this means my medical treatment, which is supposed to be given by my doctor, would be directed and decided by a bunch of greedy scumbags without any kind of medical training. A blue-shield rep even told me “..this is what you’d expect with your HMO plan…”

    So, please be warned! If you can avoid any HMO, don’t even be tempted by the luring ads. Kaiser Permanente is perhaps the worst. But Blue Shield isn’t far away.

    Remember, these blood-thrist hyenas are not in it to ‘care’ about your health. Their only mission is to make as much money as they can, using your health as the means.

    It’s an evil industry that must be destroyed before they destroy us all. It’s an industry that is worse than terrorism. It’s a cancer that must be removed.

    Comment by Larry — July 16, 2007 @ 9:09 pm

  15. I am a 22 year old and I have always been under my parents’ family coverage, but when I turned 22 I needed to sign up for an individual plan. For their underwriting process they need certain pieces of medical info from my doctor, which they obtain by sending me a request, which I send to my doctor, who sends it back to BCBS. These have slowly trickled in to me over 6 months and I have promptly sent them to my doctor. Once, after waiting more than a month with no correspondance, I called and their response was that they weren’t sure why it wasn’t being processed. Then a week later I got another request for medical info.

    Anyway, after all that, I’ve finally been approved but guess what. I have to sign a waiver saying they don’t have to cover two preexisting conditions. One of which is a shoulder injury, and whole reason I need medical insurance is to cover this shoulder injury I got a couple of years ago.

    It’s bad because they specifically said that all preexisting conditions would be covered 11 months after switching from my parents’ plan, but now (after months of trying to finally be approved) they say I need to sign a waiver exempting them from all coverage related to this preexisting condition. THIS IS THE WHOLE REASON I’VE SUFFERED THROUGH THE UNDERWRITING PROCESS, WITH THE EXPECTATION THAT IN 11 MONTHS I WOULD BE COVERED! Guess not though…

    Comment by Jared — August 7, 2007 @ 11:33 am

  16. I am going thru the exact same thing for two months with the preexisting clause with my insurance is 6mo they never told me. They say they will cover me October we will see. I am in need of surgery 2 months ago

    Comment by Debbie — September 6, 2007 @ 4:23 pm

  17. Funny how it works. My health care coverage includes a pre-existing condition and “blue cross” still denies to pay my bills. This time they asked for a lot of paper work with a proof of that condition. Where is the end?!? ARE WE GOING TO BE FULLED ALL THE TIME?

    Comment by Nathalie — September 8, 2007 @ 5:43 pm

  18. I’ve been healthy almost all my life and had very little to do with doctors and hospitals until recently. I’ve payed my premiums to BCBS for a PPO plan.
    The Specialist I consulted got my blood analysed by an out of state lab, because there are no labs in GA providing the precise information he needed for a propre diagnostic/treatment. I was not told that using “an out of state lab” when necessary could “cause” an automatic and dramatic increase in my deductible that suddenly jumped from $3.500.00 to $7.500.00 a iear. It feels like BCBS comes up with new interpretations of their regulations to avoid paying.
    I feel at a loss because I even don’t understand the language they use. Did anyone has similar experience?

    to me, BCBS PPO increased, all of a sudden, my deductible

    Comment by fera — October 3, 2007 @ 3:06 pm

  19. I’m 22,000.00 in debt because of BCBSNJ!!
    I’ve been through the loop with them, they denied all my claims, all while paying them 431.46 a month for coverage. They claim pre-existing condition, which I never had– I’m stiil battling it out and now my one bill has landed in collections because I was told by BCBSNJ not to pay because claim was still “pending”!! I’m gonna have to take legal action eventually…..

    Comment by Jackie — October 17, 2007 @ 8:36 am

  20. [...] complaints against Blue Cross Blue Shield would yield a lot of traffic. My post complaining about my problems with BCSJ Horizon of NJ has received constant comments with people posting their horror [...]

    Pingback by Interprete » My Ongoing Saga with BCBS — October 17, 2007 @ 8:53 am

  21. My wife has a disease called Lupus and is attacking her Kidneys. She has been through chemotherapy once already, this lasted for eighteen months. However about three months ago her doctors from the Samsun clinic told her she would have to have another, more agressive type of chemotherapy or she will lose her kidneys. For three months I have begged Blue Cross for her treament, but they refused to pay for it. The cost is around $70,000. I have had Blue Cross for 25 years and my employeer now pays closs to $1200 per month for premiums. I have been getting the phone tag run around since the original refusal of service. The last Blue Cross point of contact person person I had worked with, after spending three weeks thinking she was helpng me, admitted to me she was only a SALES REPRESENTITIVE. I am afraid for my wife and Blue Cross has thrown up road block after road block. I need help

    Comment by Bryan — November 4, 2007 @ 5:08 pm

  22. My husband passed away 11/5/2007 I sent a claim in multiple times-seems it was lost at least twice. 6 months later after many phone calls I received a statement saying that the claim would be paid (over $4000). Great except they forgot to send the check. I continued to call and was told that BCBS had lost their database!!!??? But they had my information and that I would be placed on a special list to have the check expedited. I still have not received the check. How can this company stay in business?

    It’s The Law That: Insurance Companies Are Required To ‘Willingly’ Pay Claims Properly And Promptly (Good Faith) And It Is Illegal To ‘Willingly’
    Discount, Delay Or Deny Payment Of Claims (Bad Faith) *

    Comment by Caryl Meade — November 15, 2007 @ 12:24 pm

  23. Oh my god!! i am going through something very similar to this. In 2000 i was diagnosed with having a benign cyst in my left breast (from 2 different doctors, as my mom wanted a 2nd opinion), which i was told would go away and was nothing to be concerned with. then, this year my new gyno wanted to send me to a breast specialist to get a biopsy taken of it. The specialist gave me a mammogram, and then a biopsy, and then told me she wanted me to remove it. i call bcbs, and they told me that would be covered…i should have know they were dirty thieves. After a long ordeal (this was a 3cm cyst) i get a letter from bcbs saying this was a preexisting condition, and therefore nothing having to do with it was covered. when i called and actually used the analogy of how i couldn’t possibly report every mole on by body for potential melanoma, or every supposed flu i have ever had, they told me that those would constitute preexisting conditions as well. nearly $5,000 later and working on the appeal, i am told that now all specialist visits require a specialist copay ($100). oh yeah, and my annual gyno visit = specialist. is there any point to insurance any more? i mean really…i wish terrible terrible things for them.

    Comment by Sarah Clay — November 22, 2007 @ 7:59 pm

  24. I am a BCBS-NJ Select PPO subscriber. We went out of network for arthroscopic surgery to repair femoroacetabular impingement (FAI) in my 17 y/o daughter. This surgery is cheaper with no overnight hospital stay required as opposed to the BCBS approved open hip procedure that requires a 4 day hospital stay. The surgery was recommended by approved BCBS doctors and we attempted to call for pre-approval from BCBS and were advised that it was not necessary. BCBS has come back now not refusing to pay anything for the surgery claiming it was a “research” procedure. We were prepared to pay the 30% for out of network required by our plan but are appalled that they refused the entire charge and claim after we attempted pre-approval that we are entitled to nothing. The internal BCBS appeal came back negative with no good explanation (as compared to our detailed and referenced appeal letter).
    I have been in health care delivery my entire professional career (~28 years) and I share the perception that BCBS is a corrupt entity that shamelessly plays the float and beats people down with endless administrative dodges. When I dealt with them for the collection of charges for lab services they typically ignored the first 30 day cycle and only paid at best after 45 days as compared to Medicare who paid within 21 days.
    Good luck to all of you.

    Comment by Tim McDermott — November 28, 2007 @ 3:46 pm

  25. I have had BCBS for many years as an individual and when I got out of college my premium was $84.00 dollars a month, now 18 years later I have a family plan with a wife and two kids. My premium as of November hs risen to $785.00 a month. How is this possible? In my state of Nebraska health companies managed to get a cap placed on Medical Malpractice lawsuits as they claimed they were a primary source of inflation in the medical world – yet all we see is a continued increase. I called BCBS and they informed me I was in fact on their most expensive plan and gave me some options to consider one plan will reduce the premium to 560.00 However I was also offered another plan which seemed great was $450.00 a month and I almost jumped….my son had cerebal palsy so it would be impossible for me to get him covered if I tried to find another company. After further probing I found out that if you switch to the cheaper plan that BCBS offers – if you decided that plan isnt for you and try to switch back you have to be medically underwritten which I am sure BCBS would then not cover my son’s CP expenses. So I guess I have to wonder are their any laws that protect us as consumers? I can’t believe that I will be forced to pay BCBS whatever they radomly decide is a fair premium because I can’t switch to anyone else due to a pre-existing condition. A 25% increase in premium which occured in November seems like robbery – when I complained to customer service she said they paid over $300 million in claims last year and they are a not for profit company. So where does this madness end? Socialized medicine?

    Comment by Bob Carter — January 4, 2008 @ 4:37 pm

  26. Well I have a Horrible story about BCBS too.. and just to let everyone know, please..please do not take BCBS insurance.. if you have an option for another insurance carrier take it..
    My son had knee surgery( Right knee) on 4/06/06 (at that time he was 15), because he teared his ACL and MCL and damaged his meniscus. As part of the post operative rehabilitation the surgeon ordered a CPM for 4 months, the need for this machine was to help regain range of motion as well as nourishing the articular surface and cutting down any chance of Arthritic changes… well just to let you know BCBS paid only 750.00 of a bill over 4000.00.and I’ve called them numerous times..no help from them .. I’ve appeal( BCBS turnaround for this appeal was 2days “WOW” ) of course they denied..”I believe they did not look at it”..
    I’m being sent to court by the company that provided the CPM, because they need this bill to be paid.
    I do not know WHY I PAY SO MUCH MONEY FOR A PPO if its not worth it!!

    Comment by Liliana Lucas — January 24, 2008 @ 7:26 am

  27. After reading some of these horrow stories, I can see why insurance companies have a bad reputation. I worked for several years for two major companies and never once did I or any of my co-workers try in any way to NOT pay a legitimate claim. Our philosophy was always pay it first time out-it is easier and cheaper than making adjustments. We were monitored in our phone conversations, claims payment and correspondence handling to do the right thing, period. HOWEVER, now that I am no longer in that field, I am experiencing the same horrors that are in this website. It is a real eye opener! One thing I learned, when you feel there has been an error and the insurance company will not listen, send a letter to the state insurance commissioner’s office. The insurance company MUST respond to all complaints and it must be within a specific time frame. Blue Cross was about to deny my husband’s surgery due to pre-existing. He has had continuous coverage for years and there are laws that protect him from the pre-existing clause. We had to submit proof of prior coverage but now all is OK. The attitude of the Customer Service dept is very poor- boredom to obnoxious- but I believe in being a VERY sweaky wheel! Hope this helps.

    Comment by Diane — February 19, 2008 @ 1:45 pm

  28. It’s the company that you work for that makes the rules in specific details of your insurance coverage. Sometimes they’ll pay for everything including sexchanges… while other employers want a pre-cert call from you while your brains are all over the road before you get in the ambulance. Sometimes it’s the hospital that is supposed to call them. If they don’t do what they need to in time the claim is denied. But you’re not supposed to be “balance-billed” for the bill according to their contracts withthe insurance companies. As far as the CPM incident… were you pre-approved by the discharge planner at the hospital calling BCBS to coordinate discharge planning? The vendor and doctor then needed to keep calling back for extensions of payment for your machine with updates. Maybe the vendor screwed up and is blaming the insurance company.

    Comment by Llyn Major — February 19, 2008 @ 4:10 pm

  29. well, i was informed last night by my daughter, a medical school student in CA, that the MRI her neurologist requested approval for from blue shield has been denied. here we go.

    Comment by Leslie Matthis — March 2, 2008 @ 10:36 am

  30. Does anyone knows how to expedite payment for overseas claims. My baby was born premature at the Philippines and hospital and doctors demand daily payment. Since the baby was born I ask for expediting processing. My baby was born 2/04/08 and the first payment was just made on 3/14/08 for services only up to 2/22/08. I feel my baby will be held hostage due to snail processing from Blue Cross and Philippines prehistoric billing “repo” type. Any insight will be greatly appreciated.

    Comment by Ismael Garcia — March 15, 2008 @ 3:39 am

  31. My husband and I ended up covered by BCBS of NJ due to a job change. We moved from CT where we were covered by ConnectiCare. For a lower premium our whole family was covered 100% from day one in CT. BCBS of NJ will not cover pre-existing conditions for the first year. So much for Blue Excellence! My heart goes out to those with terminal or chronic conditions.

    In Connecticut it is state mandated that everyone age 45 and older are screened for colorectal cancer with a full colonoscopy. Again this is paid for by Connecticare 100%. BCBS of NJ will not cover this. They will just pay for a sigmoidoscopy which does not examine beyond the first few inches of the colon while it’s well known that colon cancer usually occurs in the upper colon.

    I have (yet to be determined as to cause) several brain lesions causing neurological symptoms and memory loss. I have been referred by a local Neurologist and Psychiatrist for psychoneurological testing to determine the areas of the brain affected and assist in diagnosis. After two appeals and five months all I received was a letter stating that they warranted the test as “Medically Necessary”. However, they will only pay $500 for an eleven hour test. I have yet to find a doctor that will accept such poor compensation and BCBS is doing little in aiding me. What are we paying premiums for????

    Speaking to the reps, all apologize, admitting that the company simply does not want to pay for the test. I find most doctors either will not accept BCBS or you are given a list of providers 20 miles plus away, few of which pan out. The whole game is poor customer service, poor physician compensation, lack of decent selection, more exclusions than inclusions and high out of pocket costs.

    We have never been so disgusted with an insurance company before.

    BCBS of NJ IS a nightmere and should be avoided at all costs!!!!!

    Comment by Susan Kramss — March 16, 2008 @ 6:20 pm

  32. I am having all kinds of problems with Blue Shield!

    seems like everyone is! I wish someone would start a class action lawsuit! I would join in right away!

    Comment by Alan — May 4, 2008 @ 7:45 pm

  33. Just to update my comments #33 – It is nearing the end of May and BCBS has still not located a Neurologist for me to see.

    They have reccommended that I seek OUT-OF-STATE physicians.

    If anyone has contact numbers for higher ups I would appreciate it. I’ve written several appeals and all they provide me with is more excuses and time wasting tactics.

    The doctors I have seen out of pocket, all say – “I wish I had known you were stuck with BCBS. I would have warned you about them!”

    Comment by Susan Kramss — May 21, 2008 @ 11:51 am

  34. I have a PPO plan with Horizon BCBSNJ – This is my first health insurance coverage and I was aware of the pre-existing condition. I am reasonably healthy and have not seen a doctor since 2004.

    Last month, I discovered I had a tick on me which I had for four days. It was on my head but under my hair and I did not notice it. I had symptoms the third day and went to MedCare for diagnosis.

    The doctor said I would be treated for possible Lyme disease.

    As far as I’m concerned, this is not a pre-existing condition.

    Horizon sent me a letter saying this claim would have to be reviewed for pre-exisiting conditions and they would send my doctor a questionnaire which would need to be sent back within 45 days or the claim would be denied.

    A week later I call Horizon to see if they sent the form out to the doctor – no we didn’t they say. I said how can my doctor be expected to know to send a form back if she didn’t get one?

    I checked with my doctor to see if she got the claim and they haven’t.

    I called Horizon again and they said they would sent a form out – so we shall see – I suspect they will give me the runaround for 45 days and then deny the claim.

    If they do, I will go through their appeals process. We shall see.

    Comment by Daniel — June 4, 2008 @ 8:11 am

  35. We have had the same types of issues with Highmark BCBS. We picked up individula family insurance after leaving my job because it was less expensive than COBRA. I have come to find out that anything beyond an office visit is automatically considered a pre-existing condition and is not covered. Best example came two weeks ago. My wife doubled over in pain, and after a trip to the ER, she was diagnosed with a kidney stone. We had BCBS for just about a year, but the kideny stone was considered pre-existing. What really doesn’t make sense is that they covered the cost of the CT Scan, but not the cost of the radiologist to read it. Asses!!!!

    Comment by Skip — July 7, 2008 @ 8:05 am

  36. My headache started back in November 2007. I went to the doctor to have a physical and when I got my first of many non payment letters because of pre existing conditions I was puzzled. After reviewing my EOB and the lovely letter asking me to obtain more information from my doctor, I realized the diagnosis that wasn’t being covered was hematuria, which is basically blood in your urine. Dumbfounded, because my doctor had not even mentioned it to me, I called them. My doctor said it was such a miniscual amt that they weren’t even concerned. I said well BlueShield is denying my office visit payment because of this. So, as a GOOD member, I had my physician fill out the paperwork and return.
    About two weeks later, I get another form. This one asking for further information from my previous doctor back to 2002. First of all, why are they asking for this information? When I signed my life away and had to wait 45 days through “underwriting” to even be approved by this blessed plan, I signed for them to review my medical records. Which, had they done this, they would already know that I have NEVER been treated for hematuria. So, I go to my previous doctor and ask them to do the same paperwork. Meanwhile a month or so has passed since my November visit. At this point I have paid the bill in full as to not get thrown into collection. Another month passes and I get another letter from BlueShield. At this point, any time I see a BlueShield envelope in my mailbox I feel nausea. I open it to find another envelope requesting more information. I call the BlueShield rep and ask what more do they want from me? She tells me that oh yes, we got the information stating that you were never treated for that dx however we never received the last page with the dr. signature. We sent you a new one so you can send it back to the dr and have them fill it out again. OK, my question to her was, why don’t you fax it to them, and then get the signature and have them fax it back. Her suggestion, was to fax it to me, then have ME fax it to the dr. office.?????? I really don’t understand their thought process. After insisting that she fax it and how much of a waste of time this claim has already been she agreed to fax it to my dr. office.
    A couple weeks later- I think we are in Feb now, I get a letter from Blueshield saying my time to settle this claim is running out. I think I just about blew a gasket opening that one. Basically I gave up and just ate my $134 office visit(which I was only responsible for $13 of) because I couldn’t take the lack of customer service and complete idiotic thought process of how to handle a claim. I honestly do not know what my premium goes to pay for.
    My most recent issue is that a month ago I was awakened by a sharp shooting pain in my abdomen. I was taken to the ER where I found out that the lovely pain I was feeling was due to a kidney stone. Now I have the lovely process of going through BlueShield to prove again that I have NEVER been treated for this. I have spent the last week obtaining information and signatures from my doctors AGAIN so that I can get my bills paid.
    Unfortunately, it is not just me, it has reached through the family as well. They denied a sinus infection this winter for my daughter, bronchitis for my son, 8 and 9 year old respectively. I guess just being sick is a pre existing condition as well.
    I agree with other people in the sense that they should warn you that every little item will be thrown back at you and left for you to die trying to prove. We are self pay, and pay a pretty hefty premium a month but with three kids we wanted to have the peace of mind that we would be covered. My husband and I have had insurance all of lives and have not lapsed in coverage a day. We are young, healthy and active adults and it just seems ridiculous that they make you wait the period for “underwriting” when they don’t do ANY underwriting. Waste of paper, ink and time. What is really sad is the whole way to the ER that morning I was thinking about how much of a headache this visit was going to cause me with Blueshield.
    We were on BlueCross BlueShiled of Illinois prior to this plan while living in Pennsylvania and in the 4 years we were on that plan, we never had any issues whatsoever. Go figure. I am beginning to think it has to do with Highmark Blueshield of PA.
    I will end my ranting with a comment of the BlueShield employee re: my previous claim. She said to me, “well look at this way, once October comes you will be on the plan for a year and then you will be over your waiting period and then we pay everything and you won’t have to go through this, so that’s a plus.” Trust me, if I had not been in excruiating pain the morning of June 4th, I would have waited til Oct. 1st to be treated.

    Comment by Christina — July 7, 2008 @ 9:51 am

  37. I have about the same problem. I have to pay them every month but they don’t pay there bills and i,m stuck with tens of thousands of unpaid medical bills. I call and call and i,m the bad guy . I have insurance for a reason. I called my agent I no longer what HBcbsnj no more I have never had a problem in the past with other companies they were nice to me on the phone. This hbcbsnj have big problems paying doctors they contest almost every bill was in nessasary. It was not billed right. It was not sent to the right place. They have a list of reasons why they can’t pay there bills more than my kids have for doing chores

    Comment by william whitney — July 19, 2008 @ 5:53 am

  38. Blueshield of CA is unbelievable. I had some tests done at USC/Tenet. All came back OK. But, Blueshield keeps insisting they never received the claims. USC/Tenet says they submitted the claims twice. I personally submitted them 3 times by fax to BS with proof of transmission. So, the fifth time BS of CA finally admitted receiving the USC/Tenet claim but they got the amount wrong. The claim still has not been processed.

    Another hassle is I went to get checked over for skin cancer by a dermatologist. The dermatologist found no skin cancer. BS of CA won’t pay because BS claims pre-existing condition. I have never had skin cancer. I get checked by a board certified dermatologist who says I still don’t have skin cancer. I think BS claims I have a pre-existing condition called skin cancer that no MD can find or has ever found; never existed and still doesn’t exist. I thought it would be prudent to get checked for skin cancer and I am relieved that I never had it and I still don’t have skin cancer. I will vote for Obama. Something has to be done about healthcare in this country.

    Comment by jeffrey gillette — August 6, 2008 @ 7:52 pm

  39. I called Blue Cross at 888-706-0853, and the automated request was “Please state your ID #, without any leading or trailing letters.” The problem is, my number is “UTS O or 0 M16AG1NG.” All mixed up numbers and letters, you’ll notice. If I ignore leading and trailing letters, I still have to decide whether the O is a zero or owe, and, if it’s a zero, then the central part is 0M16AG1, which has letters in it. Is it really necessary to use such confusing numbers? And instructions? Help!

    Comment by DIXON W COULBOURN — August 29, 2008 @ 4:29 am

  40. OK, my bride called UT, and found out what we need is “M16AG1NG” I still think that’s too complicated, and I wonder if it’s by design.

    Comment by DIXON W COULBOURN — August 29, 2008 @ 4:45 am

  41. I have BlueCross BlueShield of Illinois. Recently I became elegible for medicare, enrolled, received my new card effective July 1, 2008, sent a copy of my new card to Blue Cross, and received a reply back from them thanking me for sending them this information. With medicate, Blue Cross Blue Shield is to be my secondary payer, with medicare as my primary. Now when the hospital attempts to bill Blue Cross Blue Shield for outpatient services (part B under Medicare) Blue Cross claims that I do not have medicare part B and denies my claims. This has become a nightmare!

    Comment by Walter Klingler — September 9, 2008 @ 8:41 am

  42. An update to a previous post #34

    I called Horizon on 7/22 they told me they received the information from the Dr on 6/11 and that I would have to wait SIXTY business days for a decision as to whether or not the tick bite I received was a PREEXISTING CONDITION.

    This puts the date for the decision at Aug 28, 2008.

    I waited and waited and nothing until last week when my doctor calls me and tells me that unless Horizon pay the claim they will be billing me.

    Such contrast to what Horizon say “until a determination is made you are not responsible” for the bill.

    I sent a letter to Horizon BCBSNJ requesting information by the end of this month. It has been four months since I was seen by this doctor and Horizon BCBSNJ refuse to look at my claim and communicate with me.

    The funny thing is they paid my lab fees, yet they won’t pay me doctor’s bill.

    I will keep you posted.

    Comment by Dan — October 15, 2008 @ 7:05 am

  43. Update re: posts 34, 42

    I called Blue Cross Blue Shield of New Jersey for the last time.

    The rep tells me I have a preexisting condition clause. I told her I had a tick bite and was treated for possible Lyme disease, how can this be preexisiting?

    I saw the doctor in May.

    Horizon paid the lab fees but will not pay the doctor fees. They have not refused to pay, but they are delaying payment.

    My medical provider will bill me next month if Horizon do not pay. She says she has no choice as she has filed the claim with Horizon BCBSNJ several times and they are ignoring it.

    It is now October. I have called twice this month, sent in a letter – nothing.

    Now get this…

    I said to the rep, “so basically, for the first year when I pay over $1,600 in premiums, Horizon only covers me for emergencies, everything else is preexisting.”

    “Yes” she says.



    Comment by Daniel — October 23, 2008 @ 7:15 am

  44. My brother is covered under Horizon BCBS of N.J. through a company in Illinois. ( Found out Pinnacle Foods in self- insured under BCBS OF NJ) He has been trying since June 30th to get an operation for his wife preapprvoed. Many ,many phone calls which end up with a cutomer rep emailing the predetermination departmentfor an answer. Follow up calls result in no replies from the predetermination department to the customer rep’s emails to find out if there is a hangup. We have talked to the rep’s supervisor who has put in a “special request” email which is supposed to result in an answer within 72 hours. Toady we were told for the 3rd time to wait AGAIN for another 72 hours for a reply to see if the predetermintation is hung up on something or if it will be approved. This has been a long 4 month wait for pre- approval. And now we are told that in 72 hours we might find out if approved or if they are still waiting for some bit of information. The customer rep’s supervisor’s supervisor is “aware” of this but no way to get an answer today. YOU MUST GO BY THE RULES AND PROTOCOL according to them. But they don’t tell you any rules until many many phone calls later.
    My sister-in- law’s health is meanwhile deteriorating and the end of the year is approaching quickly.
    Will she get her surgery approved and be able to schedule it this year while her deductible is met???

    Comment by amy — October 30, 2008 @ 1:06 pm

  45. Does anyone know their claim department fax number?

    Comment by Danh Vo — November 10, 2008 @ 5:01 pm

  46. See post #43

    Despite numerous telephone calls, two letters Horizon Blue Cross Blue Shield of New Jersey IGNORES me and has not paid my claim.

    I will now be taking legal action against this fraudulent company.

    This company is a SCAM. Do NOT buy a Horizon BCBSNJ policy.


    Comment by Daniel — November 30, 2008 @ 4:10 pm

  47. My doctor ordered some bloodwork in June of 2008. A month later I got a bill for over $2,000. I called BCBS to see what I needed to do to get it taken care of. They informed me they just needed some information from the company that drew the blood, and I didn’t need to do anything.
    Six months and six bills later I called them back and got the same story. Two months after that I became concerned as the bills were now saying “delinquent”, so I called back. Once again they informed me they were waiting for info. To make a long story shorter, I spent hours (and hours) on the phone over the next few weeks, trying to coordinate their information requests with the service provider and my doctor’s office. Finally, it seemed everything was resolved, they had every contact number and fax number that could possibly be required for them to get any and every information that could be of any interest to them.
    Today I got another bill in the mail. My credit is now being dinged. I called BCBS.. they are still requesting the same information. I have no idea what else to do… my doctor’s office claims they have faxed this information on three separate occasions, and BCBS claims they still need it.
    I have never, ever, ever, ever in my life seen the lack of customer service and follow-through that the staff of BCBS has provided. I simply don’t know what else to do at this point. I would never have had the bloodwork done if I had known that the whole experience would be this awful. I wish my employer offered some other insurance alternative, I really do.

    Comment by Kelly — February 26, 2009 @ 12:39 am

  48. The solution is to remove the profit motive from healthcare, to create a true system, and not just a healthcare market. Insurance corporations need to be kicked out of healthcare, hospitals nationalized, and physicians made national employees. Lawyers must be prohibited from malpractice litigation. Access to preventative care should be priority number one, a right of every citizen, not a privilege only for the wealthy or healthy.

    Comment by jim marshall — March 3, 2009 @ 2:42 pm

  49. I share sooo many of the things the fellow readers have mentioned – pre-existing condition cited, claims denied, previous address used for EOB’s and premiums. I am currently in a 3 month long battle with respect to maximum out of pocket. I have a traditional plan A/50 with a 5000 deductible, 10000 max out of pocket. and 50% co-insurance. Very high numbers and a premium above $700. In the policy/benefit booklet sent to me by BCBS, the wording for max out of pocket says :

    Maximum Out of Pocket means the annual maximum dollar amount a Covered Person must pay as Co-Payment, Deductible, and Co-Insurance for all covered services and supplies in a calendar year. Except as stated below, all amounts paid as Co-Payment, Deductible, and Co-insurance shall count toward the Maximum Out Of Pocket. Except as stated below, once the Maximum Out Of Pocket has been reached, the covered person has no further obligation to pay any amounts as Co-Payment, Deductible, and Co-Insurance for covered services for the remainder of the calendar year. EXCEPTION: Co-Insurance paid for covered Prescription drugs do not count toward the maximum out of pocket. Such co-insurance must continue to be paid even after the maximum out of pocket has been reached. EXCEPTION: The maximum out of pocket can not be met with non-covered charges.

    My question: I reached my $5,000 deductible in 2008, with $3,400 in prescriptions and $1,600 in blood tests, tests in an in-network hospital, doctor’s visits. From what I have read from above, all $5000 is counted towards my maximum out of pocket. I have paid $10,133.07 in hospital, tests and physician bills, again all in-network. I have not counted any prescriptions paid as co-inusrance in the $10,133.07 amount. By my calculations, I have overpaid my maximum out of pocket by $5,133.07 (For the record, I am a computer systems person and proficient in Excel – the BCBS web interface lets me download my claims data into excel format and I can generate my maximum out of pocket in 10 minutes. BCBS customer service does not seem to believe I can do this and I can never speak to a client service consultant – why ? )

    I have asked for about my overpaid max out of pocket 3 times in the last 2 weeks -

    I have been on the phone with customer service, been told I have an outdated book for my policy (I then called sales and was told customer service was wrong).
    Next was told the PIBA screen (PIBA is the BCBS customer service computer system) had the actual wording for maximum out of pocket from another plan and the wording would have to be updated by corporate (this is very scary because there could be other sections incorrect ? I confirmed the wrong wording TWICE now, but still no updates). It seems the error in wording also effects the rules in how the max out of pocket is calculated on their end. That was the whole point of all the phone calls.

    I have asked for a supervisor. spend 90 minutes on the phone, been placed on hold for half of that call, was told that my max out of pocket does include the deductible, and they estimate I overpaid about $4,000. The corporate person the supervisor spoke to (as I was always put on hold after every question) generated a reference number. I was told they would be working on the calculation of the max out of pocket. 4 days later a letter arrives -

    This is in response to your inquiry regarding your 2008 maximum out of pocket. After careful review, it has been determined that your 2008 maximum out of pcoket has not yet been satisfied.

    I stated in my phone call my exact calculation, and was told by the supervisor the corporate person would need some time to do an exact calculation. I said fine and agreed to wait for the letter. You can imagine my reaction to a letter that has no supporting information or numbers, and how it went from “about $4,000 over” to “not met yet”. This is for 2008 no less.

    Can anyone share some tips ? I will not give up on this – the money is way too much here.

    Comment by Edward — March 15, 2009 @ 12:52 am

  50. Last year late at night, my husband went numb on one side of his body. There is a serious history of stroke in the family. He also had a slight weakness on that side. We went to the emergency room where they admitted him for tests. We have BCBSnj direct access. I called them to obtain permission or find out if there was anything we needed to do. They said there was nothing we needed to do.

    Now they are refusing to pay for it. Reason: apparently he wasn’t sick enough so they are saying it wasn’t medically unnecessary even though he had the numbness for 48 hours!

    We are now caught in an absolute nightmare of nonsense. They say it didn’t meet Millman Standards but I say the hospital should have known this and told us.

    We are also getting the runaround on the emergency room charges…they are saying the hospital didn’t bill properly so we are responsible for it.

    We pay about 22 thousand a year for this coverage!
    Blue Cross Blue Shield is a nightmare!

    Comment by confused — March 17, 2009 @ 7:34 pm

  51. I can’t believe this non-sense, with BCBS. I had sharp abdomen pains in October of 2008. It was an emergency and I had to go to the nearest hospital. As soon as I arrived in the ER, I was sedated with Morphine. It turned out to be that I had gall bladder stones.

    I was on Morphine and other medications for about 6 days. Since it was a county hospital, in order to get surgery, I had to be on a waiting list. Since my case was not severe and it was controlled by medicine, I had to wait. Fortunately, I got better and I was released from the hospital. The hospital adviced me to go to my primary doctor for surgery referral or I could wait about 6-8 weeks (if that) for a surgery with them.

    BCBS is only paying 70% of the claim. According to my insurance plan, they are to pay 90%. Now, I am stuck with a $9,000 bill. I don’t have the money, specially during these tough economic times. Well, according to BCBS they are only paying 70% because I went to a provider that is out of network and because I had inpatient services.

    A rep at BCBS said that BCBS would have paid 90% if I had received outpatient services. I told the rep. that this was insane. I am basically getting penalized for being sick. I told her that in times of emergency specially when one is sedated with Morphine, one is not going to ask the hospital or doctor “hey wait a minute, are you within the network”.

    I am doing my research and will be seeking legal advice. For those who have had problems with BCBS, be patient and just wait and see. They are bound for a class action law suit.

    I am praying about this and I know the Lord will make justice with their injustice.

    Comment by Claudia — April 21, 2009 @ 11:54 am

  52. [...] of comments every few months, usually giving E-town a huge thumbs down. The other entry concerns my tribulations with BCBS and here I receive a steady stream of sad stories all of which point to the horrors caused by some [...]

    Pingback by Interprete » They keep on coming — April 21, 2009 @ 8:08 pm

  53. I was wondering if anyone else has had such problems with BCBS. There definitely needs to be a class action suit against them. They keep denying my claims EVERY year at least once year telling the doctors that they need information from me. Then within a couple of weeks to a month, they send me a form to complete stating whether I have additional insurance (which is something else they use to deny claims). I fill it out the SAME way every year and send it back. Then I spend the next month checking to see if they got it and if they are reprocessing the claims…end result is they get at least 2 or more months off each year of not paying claims…it is such a scam. It makes me sick!

    Comment by disappointed — May 6, 2009 @ 10:32 am

  54. I am a certified nurse midwife in New Jersey. I am one of the few providers that does home birth. I have written practice agreement with two board certified OB/GYN. I have been serving women for over 14 years. I am always paid by Blue Cross/Blue Shield if the patient has a PPO plan so clearly my services are valid. Where my clients run into enormous issues are when the have and HMO plan and need a gap exception. There are no nurse midwives in the state of NJ who do home birth that are in network. Even though it is less money for BC/BS to pay for these legitimate services they put my clients and me through all of the above mentioned hassle and such. Even letters to the company and to the insurance commission and banking don’t seem to matter. It is clear that this insurance company don’t think they have to pay for maternity care for women who chose to have a safe alternative for their birth instead of going to an institution with the possibility of infection, drug errors and forced medical procedures that are not needed.

    Comment by Judith Hagan — June 5, 2009 @ 8:34 am

  55. Does anyone have experience seeing a chiropractor out of network with BCBS. I really want to see my chiropractor but have insurance now and was wondering if I could still see him. His company is http://drnathans.com and he does not accept any insurances directly. I know I can use my HSA but was hoping that I can send my own claim in.

    Comment by Shawna — June 16, 2009 @ 6:30 pm

  56. There are things within the insurance realm that most consumers would be shocked to find out. We credential physicians with the various insurance companies and it is unfortunate that the physicians are often blamed for the unfair insurance regulations. Regarding the last post about http://drnathans.com, you can send the claim in on your own but they will not cover it under your in-network benefits. This means that the claim will fall under your out of network benefits which means your co-insurance will be higher along with your copay. Might still be worth seeing him if he is a good physician but otherwise you might see someone who is in network. Remember that many of the better physicians refuse to participate with insurance companies because of all the red tape, just something to consider.
    Hope this helps.

    Comment by Andrew Eriksen — June 30, 2009 @ 7:58 pm

  57. My gripe is with BCBS of IL. I absolutely have a class action suit brewing, I just need to find a lawyer who is willing to tackle it, which I will. Here is my long story short. Back in Nov of 2008 we started the application process with BCBS, for a PPO. My husband, son and myself each applied for individual insurance just so we wouldn’t have to double the deductible as you have to do in a family plan. It actually was cheaper. We had had Unicare for 5 1/2 years, we are both self-employed, but it was expensive so we decided to switch. My husband had had back problems, but at the time of the application the problems were resolved. The application process took 4 months. We each spoke to 3 or 4 nurses on recorded lines during that time. Somehow, the nurses I spoke to kept asking me about my back surgery, which was 12 years ago, 2 years beyond the 10 year period of time they were allowed to ask about medical history. I did not divulge that I had had surgery on the application. I don’t know how they found out, but they did. I refused to answer the questions on the recorded line because it was beyond the time period that was required on the application process. My husband too was asked all kinds of questions and he responded honestly about his back, his allergies, and his hearing.
    Low and behold BCBS of IL came back with a full Rider on my back and nothing on my husband, but a few comments on his Amendatory Endorsement. I was beyond pissed and submitted a lengthy request to remove the Rider on my policy. BCBS of IL did remove the Rider and so I signed the Amendatory Endorsement. My husband signed his as well, no Rider, no pre-existing noted.
    Well as luck would have it, my husbands back went out again. I kept Unicare for 2 months overlapping with BCBS of IL, just to see what would happen with BCBS. They paid all of the claims for my husbands back during that period, so I cancelled Unicare. Then the witch hunt started. BCBS of IL contacted all, including my sons pediatrician, and wanted them to send 10 years worth of records on each one of us. My son is only 10 years old, so that was totally absurd. I contacted all of my doctors and told them NOT to send anything. WE did not sign any releases for that to happen. And I thought BCBS of IL was suppose to do that during the application process. They certainly dug up information about me, so I thought they had done their due diligence with my husband and son, but apparently not. Now 6 months into the policy we received a full Rider on my husband’s back. We either sign it or loose coverage. BAIT AND SWITCH is illegal, why isn’t it illegal in the insurance industry. We never lied about his back. They knew full well about it and it is on a recorded line, although I’m sure they conveniently erased it. They are doing the same thing to us that they got nailed for in California, so I think I have a pretty good class action suit. They are evil and should be stopped. The CEO of BCBS of IL “earns” $1 million per month and poor people like me are getting the shaft. Not right. I have contacted the newspapers, TV stations, the CEO of BCBSIL and am just beginning to make noise. They won’t even know what hit them once I am done with this. The time is ripe for all of us to gather together and make them accountable for their illegal actions. Call your senators, congressmen and write Obama.

    Comment by susan blackman — July 4, 2009 @ 10:29 am

  58. Susan,

    Can’t wait to see the fruits of your efforts!

    Comment by Biella — July 7, 2009 @ 10:43 am

  59. I am now dealing with this garbage! I am in Utah and am getting these letters regarding my recent back troubles. I have never had back trouble before so there is no ground for this claim, which also stops my coverage while they review my history. Such a joke.

    Comment by Taylor — August 21, 2009 @ 12:35 pm

  60. They are thiefs, the worst kind. Not once has my emergency medical bills been covered by Blue Cross Blue Shield of N.C they only ended up causing me major issues. Why, because I did not fill out a questionaire stating they were my primary. Why should I fill out a questionare for the 5th year in a row. If anything changed I would speak up. Why not send me this stinking questionare on time??? .. 4 times my medical bills have been sent to creditors. I am a good American I pay bills to Blue Cross Blue Shield to insure that I will be taken care of. I would of been better off saving my money, and paying these bills uninsured. And the only doctors these fools cover are horrible the offices are dirty, the treatment is poor. They are dirtier than the Thiefs that come in the night!!!!!

    Comment by forsaken — September 21, 2009 @ 9:04 am

  61. The system we have today is quote broken.

    The insurance companies cherry pick and deny claims to keep costs down. Some consumers go without coverage when they are younger and healthier and so become part of the system until they are older and have pre-existing conditions.

    We need an overhaul of the system. I just hope that whatever they come up with is better than what we have. There is no guarantee that the new system will be better.

    Comment by Alston - CT health agent — September 22, 2009 @ 8:04 pm

  62. I have been denied payment for prostate cancer surgery by Highmark BC/BS of Pa. They say the CyberKnife radiation surgery is not medically necessary. They recommend no treatment. Doctors said i had 2-5 years without treatment, so BC/BS is essentially telling me to go die. I have found out that all BC/BS organizations around the country are franchises from a parent BC/BS headquartered in Chicago. The parent co. and all franchises are privately owned and do not report to any governmental regulatory agencies. I asked Fidelity Investments to investigate them to find out if their stock could be purchased or if any financial data was available. Fidelity could not find any information. BC/BS is like some kind of medical insurance Mafia. They should be investigated by Congress and wherever possible put out of business. They are as close to a criminal operation as you can get.

    Comment by joseph walsh — September 24, 2009 @ 12:15 pm

  63. I have been searching on the internet to try and find answers to my questions because the letters that I receive from BCBS for my Direct Blue insurance might as well be written in a foreign language. I am relieved to find that others posters on this blog are also confused by the language.

    Here is my problem. Any advice is appreciated: I pay $198.80 per month for my insurance in Pennsylvania. Direct Blue does not pay for any pre-existing condition I have for the first year of coverage, so until February 2010 I will not receive coverage for pre-existing conditions. I had assumed that meant for specific problems I have had in the past such as pre-cancerous moles that are likely to return. However, to my dismay I have discovered that “pre-existing condition” means ANY diagnosis I ever received in the past five years, whether it is a simple yeast infection or a cough, even though diagnoses such as these have NOTHING to do with prior cases. During the past 11 months I have received a letter from Highmark for almost every single doctor’s appointment, investigating for a pre-existing condition. So far several of my claims have been denied including:

    • An eye exam – since I had routine glaucoma tests done before this year, Direct Blue would not cover these routine tests this year, so I paid several hundred dollars that those tests.

    • An ear, nose and throat doctor exam – last month I was diagnosed with rhinitis, which is a runny nose, since I had a cough. Well because I was diagnosed with a cough in 2007, Direct Blue will not pay for this cough.

    • A gynecologist exam in which I discovered I had a yeast infection. Since I have had a yeast infection in the past, Direct Blue will not pay for this yeast infection. Because yeast infections are common for women, I find this particular denial along the lines of gender discrimination. The bill for this exam is over $900.

    Apparently these so called “pre-existing conditions” are costing me thousands of dollars on top of the $198.80 I pay each month for my health insurance – insurance which has proven to essentially be useless. I am a student studying to be a teacher. I do not have the thousands of dollars to pay for these three doctors visits which were for basic, simple health problems. I don’t even understand how this bullying from the insurance company is justified. I had food poisoning four years ago and ended up in the hospital, so if I get food poisoning again and it has the same diagnosis code, does this mean I will not be covered for it? Does anyone know of any way I can argue these bills? Perhaps I do not understand completely because this seems so unjust to me.
    Thank you.

    Comment by Dara — December 15, 2009 @ 1:28 pm

  64. Fascinating and disturbing. I would fight every single one of them. Start of by following these instructions:


    Let us know how it goes.

    Comment by Biella — December 16, 2009 @ 1:35 pm

  65. Here is a copy of a registered complaint my wife filed with our state insurance commissioner. It is accurate and happened just yesterday. I’m gonna post this everywhere I can until they make it right.

    “I have been paying for family insurance from Blue Cross/Blue Shield through my employer (Catholic Health Initiatives) for around two years. On three occasions, I have tried to pick up prescriptions for either of my two sons, only to have to call BC/BS and fight with them to acknowledge the children on our plan. Today, Kristopher (my 3-year old) was diagnosed with Bronchitis and an ear infection. When I went to pick up his prescriptions, once again, I was denied. Upon calling BC/BS, they told me the problem was with Medco (apparently that’s who they farm prescription coverage out to). I called Medco, they told me they have NOTHING under my name, Social Security number, date of birth, children’s names, NOTHING. They told me they get their information from BC/BS and that the problem lies with them. I called BC/BS again. They told me that they have nothing to do with Medco, it’s their problem, and that I must call them again. I REPEATEDLY asked to speak to a supervisor and was denied. I called Medco AGAIN. I realized that I’ve been paying for coverage that I have NOT been getting, so I asked to be reimbursed and that the problem be taken care of immediately as my son does not have the medicine he needs because I can’t afford it, because I’ve been paying over 300 dollars a month for fake insurance. At this point, the representative began playing dumb and said that BC/BS is responsible as they get their information from them. I AGAIN called BC/BS, they said that they’ve been sending updates every Friday to Medco as recently as December 2009 and that they would have to play fax tag with their membership department to get my son covered and it could take 72 hours. I understand that these things can take some time, but I’ve been paying for coverage that doesn’t exist and asked to be reimbursed. They also began playing dumb, eventually denying any involvement with Medco, and saying that they were a completely different entity. It’s now 6 PM, I’ve been back and forth between BC/BS and Medco several times since. Medco is now saying that the last update they received from BC/BS concerning me was March 9, 2009. Again, I called BC/BS. A BC/BS supervisor named Jill has been lying to me, providing me with fake numbers to call, and being completely rude to me since I finally was transferred to her. She is now blaming my employer. I would like to be reimbursed for all premiums since March 9, 2009. I also would like to ENSURE that this will not happen again. My 3 year old is sick on the couch and I cannot tend to him as I’ve been on the phone for 3 hours and counting. He does not have the medicine he NEEDS. They have been lying to me, stealing from me, and they should receive some sort punishment along with paying me back.”

    Believe it or not, this “Jill” person (who claimed to be a supervisor, but was just another CSR whom my wife reached on her first or second call) actually gave my wife a number to call (which she repeated back TWICE) that led to some random guy’s home phone.

    Comment by Kelly Shull — February 10, 2010 @ 7:55 am

  66. I had Unicare from 2005-2008. When Unicare decided to stop providing medical insurance in Texas, I got a letter from BCBS saying that they would take over my existing policy. The letter stated “replacement coverage” with the exception of mental health care. The only mental health care that was provided in my Unicare policy was 12 visits to a mental health professional. The only stipulation for this replacement coverage was that I keep Unicare for the last 2 months of 2008 and BCBS would take over on Jan. 1, 2009. After I signed the agreement forms and paid them, BCBS now says that they no longer cover ANY CENTRAL NERVOUS SYTEMS DISORDERS – NOT THE SAME AS MENTAL HEALTH COVERAGE. So I spent $400 per month for November and December to keep the Unicare so that BCBS would just take it over. I have now spent $400 per month for January and February and they will not cover one doctors appointment or one prescription that I normally receive. I’m out $1600 and have gotten NOTHING for my money. I have migraines 2-4 times per week and they my prescriptions. I can’t work without my meds. They will not cover any of the medications that I was on under Unicare – pre-existing conditions or central nervous system disorders. Anyone filing a class action suit for BAIT and SWITCH on insurance coverage in the Unicare BCBS fiasco?

    Comment by Victoria Womack — February 16, 2010 @ 3:49 pm

  67. Hello,

    I can’t tell you how enraged I am at Horizon Blue Cross Blue Shield of NJ. I have had a claim open with them since April 2009. My preventive procedure was a test to check for stomach ailments as I was having terrible stomach aches. My doctor called for a standard lab test to check for problems. BCBS claimed that this test was not covered normally so they need a letter of medical necissity. They said once they received the letter that it should be no problem to get it covered. My doctor, never having heard of such a problem with this test being covered, promptly provided a letter of medical necessity. This process took a couple of months because I was told that we had to send the letter first to Illinois BC, then they would send it to NJ. Not surprisingly, the letter never made it to NJ after 5 attempts and several months later. Finally I spoke with a customer service team lead and had the letter sent directly to them. Now it has been 4 months since they received the letter and it has been escallated, super-escallated, etc. at least 10 times. They still don’t have an answer. It is obvious that they are stalling in order to not pay this bill for a fairly routine lab test. I urge you when you are considering health insurance companies to listen to my story and the others on this blog. Blue Cross Blue Shield of NJ has not been helpful, their customer service has no power to solve problems, and not one person has been able to remotely help in getting a normal medical bill paid. If you have any suggestions on how I can get them to honor their obligation please let me know. I can be reached at michaelfaurest@gmail.com


    Comment by Michael Faurest — February 19, 2010 @ 7:18 am

  68. I’m in the same boat. Our Anthem rate just shot up 30%. Although, in fairness, the rate is still in line with most of the other insurers.

    Comment by Major Medical — February 19, 2010 @ 7:47 pm

  69. So BCBS will not cover my mother’s surgery because she was not refered by her primary care physician. She was admitted into the ER a couple of weeks ago, the Doc. there released her and told us she needed to see a specialist, the specialist told us we needed to get her in for a colonostipy and surgery. Then on friday at 430 the hospital calls and tells us that insurance won’t cover her costs without her primary care physician refering her (her appointment was the following monday). She’s seen three different doctors all of them saying she needs to get the tumor in her colon removed as soon as possible but insurance wont cover it because her regular physician did not refer her, so now we have to postpone the surgery until he can see her and tell us what three other doctors have already told us, that she needs to have the tumor removed asap. I am an only child and my mother is the only family I have, if the insurance company ends up killing her because we have to jump through so many hoops before they will help, I hope they believe in God, because God will be the only One who can stop me from finding away to make them pay, weather it be monitary or other! Need volunteers to stop this evil empire that we have allowed to flurish in America? Sign me up.

    Comment by Ken Smith — April 9, 2010 @ 2:58 pm

  70. I am also looking for an attorney to handle an appeal with Blue Cross Blue Shield of NJ. If there is one out there that would like to handle my case on an contingency basis, please e mail me at Fishing96@aol.com. I am sick and tired of the run around I continually receive from these people. We have a medium sized company, and pay 100% for all of our employees insurance. Unless something changes, we will not be renewing our coverage with BLBS ever again. We have left and returned to them over the years due to cost, The loyalty is quickly leaving

    Comment by Meg — June 28, 2010 @ 11:55 am

  71. I have blue cross, and my wife and I are both covered by this insurance. My wife also has additional insurance through her work. We want to do a natural birth which her insurance does not cover, but blue cross supposedly does. The natural birthing center said that for the first tome in 15 years, the insurance denied our claim because her other insurance would pay for a hospital birth. What kind of nonsense is this? What happened to the right to choose a provider, or the right to choose how to birth your child? Do they have any right to deny us. I’m considering legal action at this point.

    Comment by Daniel Hull — August 5, 2010 @ 8:28 pm

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