Money Matters

Health Insurance Audit?

I was very sick at the beginning of the year and the doctor, surgery center and anethesiaologist were out of network.

I've gone rounds with Blue Shield because the claims were not paid according to my PPO plan (70/30 for out of network).

Is there a way I can get my claims audited? Is it internal to Blue Shield or a 3rd party?

Any help or suggestions on how to get this started would be greatly appreciated! 

Thank you. 

Re: Health Insurance Audit?

  • There should be a formal appeals process with your insurance plan. If you've already gone through that and the claims are still being denied (and you think the insurance company is wrong), try your state insurance commissioner to see what remedies are available.

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  • When you say the claims are not being paid properly can you specify.

    If BCBS is suppose to pay 70% that's what should be paid for any qualifying OON claims.  Did they pay less than that or is one of the doctor's offices still charging you after being reimbursed by BCBS?

  • Are they paying based on  the "approved" amounts and not the acutal charges?
  • image Sisugal:
    Are they paying based on  the "approved" amounts and not the acutal charges?

    This is what I thought might be the issue but they will not let me know what the approved amounts are. 

  • image almond1123:

    When you say the claims are not being paid properly can you specify.

    If BCBS is suppose to pay 70% that's what should be paid for any qualifying OON claims.  Did they pay less than that or is one of the doctor's offices still charging you after being reimbursed by BCBS?

    They've paid substantially less than the 70%. It has also been very inconsistent with payments for providers being mailed to me when I've submitted claims and specifically checked for payment to be made to the providers.

    I thought that maybe the 70% that was being paid was on a different amount (set by Blue Shield for the types of services) but I can't even get that information from them when I call. 

  • If they can't tell you the exact details on the phone, then a visit to their office would do. Sometimes you can't really depend on customer service especially when it comes to claims.
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