How to get BC/BS insurance to pay more?
My daughter had a birth injury and needs a surgery that only 1 doctor in Texas is specialized to do. He has patented all 3 of the surgeries he performs. The problem is: I live in Alabama and BC/BS says I need to go to a nerve doctor in Alabama for her surgery to be covered. I’ve already seen these doctors and their surgeries DO NOT fix what needs to be fixed. They only fix the initial nerve injury…not the problems that come from the nerve injury. (unable to supinate, lift arm up straight, etc)
My daughter’s birth injury is call Erb’s Palsy. A brachial plexus injury that is caused due to the OB using too much force on her neck to pull her out of the birth canal. She was 10lbs 9oz and got stuck. The nerves that make my daughters right arm work were stretched from the spinal cord.
We have already had her nerve surgery in Texas and insurance paid $9,000 out of $88,000. I had really good insurance through Wachovia. Now I no longer work and we have family coverage through my husband’s job…which is a small company and no where as great as my insurance was. Now BC/BS barely wants to pay a penny for this out of state surgery and won’t get me to a person to talk to, to try and negotiate.
Oh I forgot to mention I also took $5000.00 cash that was required the day of surgery. (Thank goodness for our family who all gave us the money to pay this)
The surgeon in TX does not accept Reasonable & Customary, which is the amount that BC says the surgery is “worth” They can do that because it’s out of state and that’s the only amount they are willing to pay. I’ve appealed and appealed the last surgery to no avail…they haven’t paid any more.
Does anybody know anything that I can do to get insurance to pay more for her surgery?!
My daughter needs 1 more surgery to fix the deformity in her scapula that decrease the use of her arm.
Sorry this was so long.
Thank you for taking the time to read it 
Charlene
Tim
You might call your Dept. of Insurance or Insurance Commissioner for help with your health insurance.
And, sorry that I don’t know much about health insurance. Hopefully some other posters will give you more help.
It might help if you post your question under the category, education, then under that pick special education. There are people there that know about special health issues and disabilities.
Vincent
if the OB caused the injury have you tried suing the doctor.they have malpractice insurance and would probably settle if you can prove it was a birth injury caused by too much force.im not a person who would just go sue people for anything but if the doctor injured her then the doctors insurance should pay to fix the injury not you. best of luck!!!
Arlene
Ok, you actually have 3 routes I would take.
1. Contact the state department of insurance and appeal. However, the appeal most likely isn’t going to do much good. Its an out of network doc and they can reimburse you at R&C and the doc can charge anything he wants to. You are probably stuck.
2. If its still an option, get Cobra on the baby only. Its going to be around the $300 each month, but it sounds like you will have much better coverage.
3. You really need to get an attorney. If you can prove negilegence, you should get all these bills paid by the Ob’s malpractice coverage.
Earl
Getting BCBS to pay anything when there is only one doctor in the country who can do the surgery is unusual. Usually, BCBS will say that anything that rare is experimental and not cover it at all.
You could try either a lawsuit or the state insurance department.
Marc
BXBS is perhaps the worst insurance company out there. Their ‘reasonable and customary’ rates don’t come close to what the actual rates really are. They pay the lowest reimbursement rates to providers and hospitals (sometimes they don’t pay anything at all), but advertise how good they are by calling patients after surgery to see how they are doing, etc. Don’t fall for those tricks. As for the surgeon, ask him if he will allow you to pay the difference on a payment plan. Many physicians will allow you to pay with no interest as long as you pay monthly.