Get The Picture? By Sherry Hopkins

Published 12:00 am Friday, March 27, 2009

‘New best friend’ became friend by deed

In February I wrote a column  entitled “I Should Have Known.” The story in part was about a tangle I (we) have had with a California laboratory and Anthem Blue Cross & Blue Shield medical insurance.

As I wrote, Dear Don needed to have a very specific genetic blood test to see if his body would tolerate a new medicine to battle the Crohn’s Disease he has had for over 20 years. The oral medicine that he is on now was and is supposed to put him back into remission, a place he really wants to be. Crohn’s is an inflammatory bowel disease for which there is no cure. But remission can be achieved with certain medications.

The medication Don is on now is the last resort so to speak for oral medication to accomplish this goal.

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He had the blood test at the Cancer Center in Oxford, which would be considered an in network facility. However, the Cancer Center only drew the blood sample. The sample was actually sent to California for testing. Here’s the rub. The California lab is the only lab in the whole country that can process and test this sample. I remember at the time the nurse telling us that “the lab would probably not be considered in network by our insurance company.” I also remember casually remarking to the nurse that it was OK because at worst we would only have to pay 30 percent of the bill and that would be after write-offs etc. I don’t remember giving it another thought.

That is until we received a bill from the lab for $395 for the test. They  “graciously” offered us a 35 percent discount if we would pay the balance, $256.75, in 30 days.

I called the lab and declined their offer and asked then to please file this claim with our insurance company which would pay them and I would then pay the balance. How naïve of me. The actual date the blood was drawn was 08/01/08. The date of my first phone call was 09/16/08.

On this date as well I faxed over all our insurance info to the billing office of the lab.

I called the lab office regularly to see if they had been paid by Anthem. Each time I was told no and to check back in 10 days. This process went on for 2 months.

Then I received an explanation of benefits (EOB) from Anthem saying they had received the claim and had written off all but $166 that we were responsible for because not all out-of-network claims are covered. Some fall into a deductible situation.

So now all I had to pay was $166.  I called the lab and offered my $166 and was told that “no, they weren’t required to accept any discounted amount” because they had no contract with BCBS. I still owed the whole $395 because my 35 percent discounted offer was now off the table.

But, Tony at the lab billing office said he would file an appeal with BCBS to ask them to accept the lab as in network. “It won’t be a problem,” he said, “we do it all the time.”

Yea, I remember thinking, now we’re getting somewhere. That was 12/19/08. The appeal process would take 30-60 days to complete. Check back in 40 days he advised. So, to the back burner it went until after the holidays.

On 02/03/09 I called the lab to check the status of the claim. No response from my insurance company yet, I was told. Call back in four weeks. At this point I decided to go ahead and pay the bill myself. We had been dealing with this problem long enough and I was beaten by the system.

I anted up the amount due reluctantly, but knew in my heart that I needed to just let it go.

Even though I had settled the claim, this past week I called the lab again just out of curiosity. No word from BCBS.

“You should call them,” the billing clerk advised. And I did. Just like a pit bull and after dealing with seven different billing clerks at the lab and just as many at BCBS I was now ready for a fight. But I got the pleasure and luck of speaking to Phyllis at Anthem.

This is what Phyllis told me. The lab knows they have to call and verify out- of-network status with Anthem BEFORE processing the bloodwork to be considered in network. We have had this conversation with the lab many times. An appeal cannot be made after the fact, and there was no appeal on file or in process at Anthem at the time for this testing on 08/01/08.

Phyllis then excused herself and puts me on hold for several minutes. Apologizing when she returned she told me BCBS has a new onetime out- of-network acceptance policy plan. You can waive the process of out- of-network one time with this particular lab and it will be considered in network. Phyllis has never used this one time deal before and needs a few days to read up and figure out exactly what needs to be done on her part and ours. Why has no one told me this before I invested seven months and $395?

A few days later after returning home from town I had a message on my machine from Phyllis.

“Call me,” she said.

I called her immediately and she said she could hardly wait to call. She is three hours ahead of us and wanted to call at 5 a.m. It would have been fine. I assured her I was up.

“I got them to pay the claim,” she said.

“You got the claim paid?” I asked incredulously.

“I can’t believe it,” I shouted. “Will they pay me back?” I inquired.

“Yes,” she said. “You should get a check in 5-7 days.”

“Phyllis I love you,” I said. “I wish I could put down this phone and run to hug your neck. You’re wonderful. You have gone beyond the call of duty. You have been so courteous and professional and helpful. I can hardly wait to tell my husband. You have made my day. And I thank you from the bottom of my heart.”

This time it wasn’t the “principle of the thing” it was the money. At a time when we are learning to live on a smaller budget, $400 is a lot of unexpected out-of-pocket money.

But thanks to my new best friend Phyllis in a few short days I can add that money back to my account. I’m gonna call President Obama and ask to have some of that AIG executive bonus money thrown Phyllis’ way. She really deserves it. She’s my hero. Thanks Phyllis.

You get the picture.