Hey everyone, I’m facing a tough situation with my health insurance and could really use some advice. BCBS denied my claim for emergency back surgery that I had last November. It cost $60,000. Here’s my story:
I had to have surgery within 24 hours after seeing a neurologist because I had a herniated disc pressing on my sciatic nerve. It was urgent since I was at risk of permanent nerve damage in my foot; I couldn’t even walk at that point. There wasn’t any time to get pre-authorization.
After the surgery, UNC Health didn’t ask for post-procedure authorization from my insurance. Instead, they sent me a bill without any proof of medical necessity, leading to the claim being denied. We’re now on our third appeal, and even after submitting more information, things don’t look good.
Interestingly, I had to undergo a second, more invasive discectomy only two weeks after the first one. With that surgery, UNC quickly submitted a request for authorization after the procedure, and Blue Cross approved that without any issues.
I feel that UNC Health dropped the ball by not getting authorization in time for my first surgery. I’ve already talked to my employer and their BCBS contact, but they said there’s nothing they can do after reviewing the matter.
I’m pretty sure this third appeal will be denied too. What should I do next? Has anyone faced something similar? I would really appreciate any advice.
Emerson said:
Isn’t that procedure usually not considered an emergency? Were you actually admitted to the hospital?
Unfortunately, you’ve got a point. I experienced something similar when my disk shattered into my nerve column and I lost feeling in my entire leg. I had to wait about a week for my already scheduled surgery. I did suffer some long-lasting damage, but with my condition, there was no assurance that the nerve damage wasn’t already occurring.
I can’t speak for the person who posted this case, but in general, this isn’t categorized as emergency surgery. Getting authorization takes time. They could have admitted the patient or sent them home for bed rest while sorting it out. It’s frustrating, but it’s often how things go.
@Emerson
Luckily, I was already set for a spinal fusion about a week later. Once the pain faded, my whole leg was numb and somewhat dragging. I ended up breaking two toes in recovery because I had to walk right after surgery. We tried going up some stairs and I couldn’t feel my foot at all, so I accidentally kicked a stair way too hard. Oops.
So they covered the second surgery with no out-of-pocket costs for you? Since they’re a network provider, I hope you’re not wasting effort on this appeal. Let UNC handle it. Review your EOB; I doubt BCBS assigned any amount that you owe. This could just become a write-off for them.
A spine surgeon (whether a neurosurgeon or an orthopedic surgeon specializing in the spine) is the one deciding on urgency, not a neurologist.
Furthermore, conditions like cauda equina syndrome and other neurological disorders are treated as medical emergencies. Alone, sciatic nerve compression usually doesn’t qualify as an emergency needing surgery within 24 hours.
What documentation have you provided to your insurance company during the appeals? What reasons did they give for the denial? You should have written proof.
If they are, they must cover the surgery costs. If you’re seeing bills and your EOB states you owe nothing, call your insurance. Ask about balance billing and get that sorted.
If the provider is in-network, they carry the full responsibility to secure proper authorizations. They have to get that authorization and have a grace period to retroactively authorize urgent or emergent procedures. They may have missed those deadlines.
If they are in-network, you should owe nothing if the payer refuses payment due to lack of auth.
I had a very similar surgery that led to a spinal fusion. It’s not categorized as an emergency. Your doctor may have labeled it that, but it really isn’t. For this kind of surgery, prior authorization is necessary.
Consider asking about a payment plan.
My pre-authorization took three weeks, with several peer-to-peer reviews.
It’s your duty as the insurance holder to check with your insurer to see what’s covered. Your doctor dropped the ball here.
There are free AI tools now to help with appeals. Just search it or check out resources like Counterforce Health’s free appeal generator. It might take some effort to fight back, but if you appeal, you can probably win at least 50% of the time.
If the provider is in-network, this might not be your issue.
If the insurance keeps denying, the provider likely has to absorb the cost, not you. Check your insurance info for any “patient to be held harmless” clauses.
Consider reporting Blue Cross Blue Shield to your state’s Department of Insurance. They should pay this and seem to be trying to avoid doing so. Your state can provide assistance at no charge.