Rescinding a pre approval for surgery

[redintheforest]

What is the name of your state? Virginia

Anthem blue cross/blue shield approved my co-worker for a complete hysterectomy. After the surgery, they contacted her deciding that it was a pre exsisting condition and will not pay anything toward the surgery.

Once approved, can they rescind the approval? She never would of had the surgery if it was not approved.

Your time is appreciated.

[somarco]

Certainly.

The carrier is not obligated to pay the claim once a full investigation of the circumstances is complete.

Based on what was posted, She never would of had the surgery if it was not approved, one must also assume the surgery was not medically necessary.

[jwmc]

It really depends on the circumstances. In some cases a third-party utilization review company for the PPO may grant approval for the surgery; yet, once the claim comes in the door to your insurance company and the claims approver looks at the plan provisions and the eligibility, it can be rescinded. Especially if it was a pre-existing condition.

Did she have something in writing from the UR company or the insurance carrier? Or did she just call up some rep at the insurance company?

[averad]

What information was given showing the surgery was pre approved?

This may have been played on the customer service line or writen in a mailed letter.

"The information posted in these documents does not guarantee eligibility for or entitlement to health care benefits."

[somarco]

JWMC -

BX does not contract with third party MCO's, they use their own internal network.

[jwmc]

Averad's right--if they just called up the customer service line and talked to a rep, almost all companies have some kind of disclaimer in the beginning that it's an estimate of benefits and not a guarantee. Get it in writing. Still not a guarantee, but usually then someone more knowledgable has looked at it than a customer service rep. Especially if their name is Apu.

[Betty]

I know some people have their doctor send their medical records to the ins. co. for review & pre-approval of surgery.. They then ask for a pre-approval in writing sent to them and/or their doctor. If pre-approval is given, in most cases the surgery (claim) will be paid, especially if not having the surgery would be a danger to insured's health.