Hello everyone, I really need some help. I’m facing a tough situation with my health insurance and could use your advice. BCBS turned down my claim for emergency back surgery that I had back in November.
I had to get surgery within 24 hours after visiting a neurologist because of a herniated disc that was pressing on my sciatic nerve. The situation was critical since I was at risk of permanent nerve damage and couldn’t walk at all. I didn’t have time to get pre-authorization.
After the surgery, UNC Health did not request post-surgery authorization from my insurance. They sent a bill without mentioning why the surgery was needed, which led to the denial of my claim. We’re now on our third appeal and it’s not looking good so far.
Interestingly, I had to go for a second, more complex discectomy only two weeks later. This time, UNC quickly sent in a request for authorization after the surgery, and Blue Cross covered it without any issues.
I think UNC Health might be at fault for failing to request timely authorization for my first surgery. I’ve got my employer and their BCBS rep involved, but they said there’s nothing they can do.
I’m expecting this third appeal to be denied too. What should I do next? Has anyone faced something like this? I’d appreciate any advice.
They approved your second surgery at no cost. They’re part of the network. I doubt you’re making progress with appeals, let UNC handle it. Look at your EOB. I doubt BCBS assigned you any responsibility, so that cost should be on the provider.
Hollis said:
That surgery doesn’t usually qualify as emergency. Were you actually admitted to the hospital?
Unfortunately, you’re right. I dealt with something similar - my disk shattered and I couldn’t feel my leg. I had to wait a week for the surgery to go ahead. I had some lasting damage but with my condition, nerve damage could have started previously.
I don’t know the exact details of the original poster’s case but typically, this isn’t considered emergency surgery. Getting authorization can take time. They could have admitted him or sent him home on bed rest while sorting this out. It’s crazy but that’s usually how it works.
Hollis said: @Tatum
I herniated a disc in my neck. I couldn’t feel my left arm. It wasn’t considered urgent.
I work as a recovery room nurse and am familiar with what classifies as emergency.
I was fortunate to have a spinal fusion already scheduled soon after. Once the pain reduced, my leg felt numb. I ended up injuring two toes in recovery because I had to walk pretty soon after surgery. We tried some stairs and I couldn’t feel my foot, so I accidentally kicked a stair too hard. Oops.
Keep in mind, a spine surgeon (either a neurosurgeon or an orthopedic specialist) decides how quickly surgery is needed, not the neurologist.
Cauda equina syndrome and similar neurological issues are emergencies. But just having sciatic nerve problems isn’t generally considered something needing immediate surgery.
What documentation have you given the insurance during appeals? Also, why did they deny it? You should have written proof.
If your denial code is CO-197 and the hospital is in-network, you can relax. That’s your provider’s problem; they cannot bill you. (My son got a free surgery that way.) Check your EOB to see what it shows.
I had a similar surgery and ended up needing a spinal fusion. It’s not emergency surgery; your doctor may have called it that but it’s not. For such surgeries, prior authorization is essential.
Ask for a payment plan.
My pre-authorization took 3 weeks with multiple peer reviews. It’s your responsibility as the insurance holder to check with your insurance about what’s covered. It feels like your doctor dropped the ball.
Sadly, there are plenty of neurosurgeons without ethical standards, and some neurologists who will claim that a herniated disc warrants surgery or even that it requires urgent surgery.
There are free AI tools now to assist with appeals - just look it up or check Counterforce Health’s free appeal generator. You need to spend some time fighting back, and you can win about half the time or more.
If they are part of the network, they must obtain the correct authorizations. They have a duty to do so and usually have a grace period for urgent procedures. They might have missed those deadlines.
If they’re in-network, you shouldn’t have any financial responsibility if the insurance denies the claim due to lack of authorization.
Consider reporting Blue Cross Blue Shield to your state Department of Insurance. It sounds like they should be covering this and are trying to back away from it. Your state can help you without cost.