For Anybody who has Blue Cross, Blue Shield

A forum to discuss Chronic Cerebrospinal Venous Insufficiency and its relationship to Multiple Sclerosis.

Postby Kathyj08 » Mon May 09, 2011 11:00 am

WeWillBeatms,
Sorry for the delay in replying to your question.
When I received the call they didn't specify, but I am of the opinion that it is all branches of BC/BS. Mine is Anthem BC/BS and the info they referred to when speaking with me was BC/BS in general.
I did get an e-mail from Dr. S's office in regards to my (hopefully) fall re-treatment and it mentions that it may be covered.
They may be telling me that because I have not had a ms diagnosis. I still need to start that investigation with the ins. co. because I feel it will be a long process.
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Postby 1eye » Mon May 09, 2011 11:46 am

They may be telling me that because I have not had a ms diagnosis.

Is this the new leprosy? Should I get a shirt that says 'unclean' on it? Or will 'on placebo' do?
"Try - Just A Little Bit Harder" - Janis Joplin
CCSVI procedure Albany Aug 2010
'MS' is over - if you want it
Patients sans/without patience
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Re: AAC billing

Postby newlywed4ever » Wed May 25, 2011 8:43 am

newlywed4ever wrote:Here's what AAC has done to me...

First, please note that I think the world of Dr Sclafani and do not wish to hurt him and what he is doing. However, I am very frustrated with AAC billing. I had my 2nd procedure 1/28/11 by Dr Sclafani (my 1st procedure was with Dr Siskin and BC/BS covered 100%). Prior to my appt., Deb Helmer of AAC billing told me that she tried to get pre-auth from BC/BS - which BC/BS denies ever getting a call from AAC and indicated the pre-auth was unnecessary. I did get the procedure & diagnosis codes from Ms Helmer and called BC/BS myself. I was told that all the codes were covered and Dr Sclafani is an approved provider. When I told Deb Helmer this, she indicated verbally that she had "a bad feeling" about my insurance covering this and I would be required to self-pay. I kept my appt. with AAC feeling that I had covered all bases. At AAC, I again indicated to Nancy (office manager) that I was told by BC/BS that the procedure was covered and that it was probably in AAC's best interest financially to bill the insurance company. I also indicated to Nancy that I would guarantee payment if the procedure was denied. Nancy told me that it came from billing that I would have to self-pay the discounted price which I then put on my credit card (yikes). I still felt confident that I would be reimbursed in a timely manner. I rec'd an itemized statement from AAC to submit to BC/BS. The itemized statement showed the procedure billed at $10,000. I submitted this and BC/BS processed a check on 4/5/11 - however, since they only cover a percentage of the cost, the reimbursement was only a little over $5300. BC/BS sent this check to AAC (by contract, they must do this and then the provider reimburses me). Numerous phone calls were made to AAC with different excuses as to why they hadn't reimbursed me. As of 5/2/11, AAC told me they had to send the check back to BC/BS due to a new Medical Policy from Empire BC/BS that CCSVI was not covered. The AAC contract manager at AAC claims that this is retroactive and all $$ rec'd prior to 4/12/11 will have to be paid back to BC/BS (I find this hard to believe). I have a copy of the Medical Policy and it states: "Venous angioplasty is considered investigational and not medically necessary for the treatment of multiple sclerosis." Dr Sclafani has always indicated that he is NOT treating MS, he is treating CCSVI.

This whole mess has been financially and emotionally taxing. Anyone else with similar problems from AAC billing? My belief is that Ms Helmer made a very costly mistake and I am the one who ultimately loses.


The saga continues :evil: Again, AAC billing was not truthful with me when they told me they returned the check to BC/BS; AAC cashed the check and never reimbursed me or BC/BS. BC/BS provider relations is now involved and AAC is telling them I was not willing to wait for pre-auth (another lie - my appt was scheduled in Nov. 2010 for Jan. 28, 2011!). The good news is that the BC/BS rep told me that the outcome will be favorable to me and I will be reimbursed for the $$ I paid - I interpret this as the whole $10,000 - keeping my fingers crossed!

P.S. No reference was made re: new medical policy.
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Postby Cece » Wed May 25, 2011 8:53 am

The good news is that the BC/BS rep told me that the outcome will be favorable to me and I will be reimbursed for the $$ I paid - I interpret this as the whole $10,000 - keeping my fingers crossed!

At least there's some good news in there!!
Very glad you have BCBS fighting for you in this.
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Reimbursement

Postby dianabee » Thu May 26, 2011 3:56 pm

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I am just shocked that this happened to you. I am not familiar with bcbs but if this is a ppo arrangement and the provider is in network, the provider has  to accept whatever payment bcbs sends, which would mean you should get the entire 10 thousand back.
so unacceptable on aac's part. Hopefully they have a reasonable explanation and good for you for keeping the pressure on.
I wonder if anyone else has had billing problems with them?
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Postby newlywed4ever » Thu May 26, 2011 6:10 pm

Thanks, dianabee! You are absolutely right - BCBS is an in network approved provider and they did not adhere to contractual language. Luckily, BCBS is investigating this and on my side (I've been on the opposite side whereas I was fighting BCBS in the past). I really think that "someone" in AAC billing screwed up royally and now they're trying to cover their a--.

I have not heard of anyone else having problems with AAC billing and I would not want people to avoid AAC because of my own very unfortunate experience. My personal opinion is that Dr Sclafani is the best... and, hopefully, their billing dept. is now more knowledgeable...
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Postby bestadmom » Thu May 26, 2011 6:59 pm

I bet if Dr. S knows about this, he'll have AAC reimburse you right away, then heads will roll. With him, it's all about being truthful.

I had two procedures with the good doc before AAC, and I needed a precert. I was told by AAC that I didn't need one for my April treatment. I had a bad feeling that I'd get caught with a huge bill so I requested everything in writing, which I still have. The claims were submitted but insurance hasn't settled them all, just one which they denied as a double charge.

Legally, if a doctor or practice accepts your insurance, by contract you are only responsible for your copayment once your deductible is met. You will get your money back and AAC is on the hook. But what a waste of time and effort on your part to do the job of someone who is clearly incompetent.
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Postby newlywed4ever » Sat May 28, 2011 6:52 am

bestadmom wrote:I bet if Dr. S knows about this, he'll have AAC reimburse you right away, then heads will roll. With him, it's all about being truthful.

I had two procedures with the good doc before AAC, and I needed a precert. I was told by AAC that I didn't need one for my April treatment. I had a bad feeling that I'd get caught with a huge bill so I requested everything in writing, which I still have. The claims were submitted but insurance hasn't settled them all, just one which they denied as a double charge.

Legally, if a doctor or practice accepts your insurance, by contract you are only responsible for your copayment once your deductible is met. You will get your money back and AAC is on the hook. But what a waste of time and effort on your part to do the job of someone who is clearly incompetent.


Thanks, bestadmom! I have mixed feelings about getting Dr S involved. I'd much rather he continue to perform procedures, educate us, etc. - rather than hassle with billing problems that are not his fault :( He did respond here earlier on this thread and believes Deb Helmer had forewarning about BCBS's new medical policy. I did not correct him that my procedure was done before the policy was issued AND the appt. was made in Nov. 2010. Hopefully, I won't have to bother Dr. S.
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Postby bestadmom » Sat May 28, 2011 7:07 am

I think Dr. S will stumble upon this thread one way or another. I hope the problems you're having aren't pervasive.
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Postby Johnnymac » Sat May 28, 2011 7:51 am

I'm sure this was just an individual mistake here, I had a good experience with AAC billing and I'm sure they will make everything right for you.
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Postby Cece » Sat May 28, 2011 12:07 pm

I had no issues with AAC billing, really the whole trip was snag-free.

It was the waiting for Dr. Sclafani to completely change where he worked and start up fresh with AAC that was the hard part! :)

Newlywed, keep us posted on how this goes, I think it's looking good now from what you've said and that BCBS will help make this right.
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Postby silvercharged » Sun May 29, 2011 6:28 am

We are about to enter this battle as our insurance is BC/BS with a twist. Dr. Underwood thinks it may be a bit different as our insurance is PEEHIP (Public Education Health Insurance Plan).

It was run up the flag pole last Thursday so we will see, regardless, we are prepared to go private pay if needed.
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Postby coach » Mon Jun 06, 2011 9:05 am

We have BC/BS and pay a lot for it. My husband is a small business owner. I certainly hope they don't expect a retroactive payment for the procedures I had. Seems like the insurance companies come out on the winning end. I'm not opposed to companies making money, but have a problem when they do so at the expense of patients when they pay handsome premiums.
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Postby newlywed4ever » Mon Jun 06, 2011 6:58 pm

coach - according to my lawyer friend "there's no way in hell BCBS can demand payment from patients or providers for procedures that were covered at the time".
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Is it really MS?

Postby Rosegirl » Tue Jun 14, 2011 12:23 pm

My first venogram was paid for by CareFirst. Unfortunately, I was part of the Georgetown University so-called study where everyone was undertreated. They also paid for a second procedure by another doctor. That also made no difference in my condition, even through five major blockages (70-95%) were treated.

In a followup visit with my neurologist - an early CCSVI proponent -- we discussed whether I should stay on Tysabri. We concluded that the venogram proved that I had a vascular problem and -- in MY case -- I could stop taking Tysabri.

Since my only problem is that I can barely walk, and that this can be due to a vascular problem, my neurologist said it was his opinion that I don't have MS.

When it's time for the next treatment, if Blue Cross won't pre-approve treatment, I plan to get a note from the neurologist.

Maybe this will help someone else who's in a similar situation?
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