It’s been some time since last we “spoke” and for good reason – I was too upset to author anything that wasn’t laden with partial sentences and potentially some profanity. I received yet another bill from Bayfront Medical Center for $10,764.14. This saga is developing into a Greek tragedy – let’s hope no one dies in this one though! Along with the second bill I received two explanation of benefits (EOBs) from my plan, Blue Cross Blue Shield of MA. The first EOB was in response to the hospitals first claim where they submitted the claim as an “overnight stay” claim and not an “emergency”. Because Bayfront coded the claim that way, the plan denied it in full because there was insufficient medical justification for the stay. The hospital then submitted the claim a second time and this time the plan denied with the following explanation:
Benefits cannot be provided because our clinical review team determined that the service does not meet medical necessity guidelines or the requested clinical information was not received. Our clinical review team gave individual consideration based on the material available. Please refer to your plan materials for information about our medical necessity guidelines. You are responsible for the charge.”
Wow. I can’t even begin to describe the level of dissatisfaction I felt after reading this. Let’s break this one down sentence by sentence.
Benefits cannot be provided because our clinical review team determined that the service does not meet medical necessity guidelines or the requested clinical information was not received.
I called the member service line and I was ready to fire with both barrels because I didn’t understand this sentence. They denied me because it wasn’t medically necessary OR they didn’t have any information with which to generate an informed opinion? What kind of statement is that? Turns out it was the later, there was no clinical data sent with the claim, which of course doesn’t normally come with an emergency room claim resulting in a hospital admittance AND no one from the plan had contacted me OR the hospital to inform them of that.
I did speak with a VERY HELPFUL member services representative – Rachel. Rachel, on the off chance you read this I hope I spelled your name right. She told me that she can see what happened and why they’re probably denying the claim and is happy to contact both the clinical review team AND the hospital and work this out because in her opinion there’s no reason to deny the claim.
Now – this raises a few questions. Rachel was very helpful – to be sure – but what does that say about the process?
- Why is Rachel, a member service representative, able to review the claim and in less than one minute understand what’s wrong and what needs to be done to resolve the claim BUT the “clinical review team” could not? Does this mythical clinical review team actually exist OR is it more likely that there is a program somewhere in the nefarious bowels of the plans computer system that is coded to simply reject a claim of this type when submitted against a plan of the type I enrolled in?
- If the clinical review team does exist, why would they (notice the use of a plural pronoun as that is the generally accepted inference when using the noun team) collectively not have the same skill set as the member services rep? By definition a team is most likely paid more than an individual yet in this case less effective? Hmmmmmm
Our clinical review team gave individual consideration based on the material available.
No they didn’t! They didn’t even give enough INDIVIDUAL consideration to put an individual denial reason on my EOB. This is clearly a VERY broad denial code.
Please refer to your plan materials for information about our medical necessity guidelines.
I went to the member services portal and clicked on the links for my plan and the information pertaining to medical necessity guidelines was nowhere to be found. I searched the member services portal using their search box and the string “medical necessity guidelines” and I received 10 hits, the first two being the same thing:
Medical necessity is a term used to refer to a course of treatment seen as the most helpful for the specific health symptoms you are experiencing. The course of treatment is determined jointly by you, your health professional, and your health plan. This course of treatment strives to provide you with the best care in the most appropriate setting.
Really? Really? This is what’s on the site when I go to search for a specific term mentioned in a DENIAL code? This definition does not square with my experience. The course of treatment was not determined jointly by me, my health professional and my plan – it was unilaterally denied by my plan without any INDIVIDUAL consideration whatsoever. Interesting, no?
You are responsible for the charge.
Well this is a fine how do ya do isn’t it? Of course I’m responsible for the charge, you just denied it didn’t you? This is unnecessary and frankly a little offensive.
So what’s next? Well, Rachel called the hospital and called me back to tell me things are moving along nicely so I’m back to waiting. In the mean time I have begun to explore what it is like to eat following a gluten-free diet. I will be publishing a series of experiences and product reviews related to that topic shortly – stay tuned.