Hien Shields faces an $18,926 bill for emergency spinal surgery after Anthem Blue Cross and its partner Carelon point fingers over authorization. She\u2019s made 80 calls over 21 months \u2013 but with the insurer\u2019s two-year claims deadline looming, can anyone fix this?<\/p>\n
Question <\/p>\n
I desperately need your help with Anthem Blue Cross. Almost two years ago, I underwent emergency spinal surgery after an accident \u2013 it was medically urgent to prevent permanent damage. My health insurance company, Anthem Blue Cross, paid the hospital, ICU stay, and anesthesiologist without issue. But it has denied the $18,926 surgeon\u2019s fee, claiming it lacked authorization from its third-party partner, Carelon.\u00a0\u00a0<\/p>\n
Here\u2019s the maddening part: Carelon repeatedly states that \u201cno authorization is needed\u201d for this emergency procedure. Anthem and Carelon refuse to talk directly, leaving me and my surgeon\u2019s office stuck in the middle, making over 80 phone calls to try and resolve this issue.<\/p>\n
Every time we follow Anthem\u2019s instructions, it rejects the claim weeks later for a new reason: \u201cmissing records\u201d (they misfiled them), \u201cwrong appeal form,\u201d or \u201cuntimely submission\u201d \u2014 even when we acted on its directives. We filed multiple appeals, including one Anthem specifically requested during a three-way call. They denied it anyway.\u00a0\u00a0<\/p>\n
The cruelest twist? Anthem imposes a strict two-year deadline to resolve claims. Our window slams shut in a few weeks. I\u2019m exhausted and terrified of being stuck with this bill. What can I do when the insurer and its own partner can\u2019t agree on their rules? \u2014 Hien Shields<\/strong>, Sunnyvale, Calif.<\/p>\n Answer\u00a0 <\/p>\n After having emergency surgery, the last thing you should face is a 21-month odyssey through a bureaucratic maze built on contradictory demands and missing paperwork. Anthem\u2019s obligation wasn\u2019t just to process your claim \u2013 it was to provide clear, consistent guidance and ensure that its partners, such as Carelon, are aligned on policies for urgent care. (Carelon provides medical benefits management for Anthem.) Instead, they left you mediating a dispute between their own departments. That\u2019s inexcusable.<\/p>\n Under state and federal law, Anthem was obligated to cover emergency services deemed medically necessary without requiring prior authorization. Anthem paying the hospital and an anesthesiologist tacitly admits this necessity. Denying the surgeon\u2019s fee contradicts their own acceptance of the emergency.\u00a0\u00a0<\/p>\n When Carelon stated no authorization was needed, Anthem should have resolved the internal disconnect immediately. Forcing you and your provider to shuttle messages between them violates basic claims handling standards.\u00a0\u00a0<\/p>\n Berkshire Hathaway Travel Protection<\/a><\/strong> covers consumers and their travel dreams, backed by Berkshire Hathaway Specialty Insurance Company\u2019s financial strength and security. Choose travel insurance designed specifically to your trip and travelers, plus the fastest claims payments in the travel insurance industry. Get more information at Berkshire Hathaway Travel Protection<\/a>.<\/p>\n \ud83c\udfc6 Your top comment<\/p>\n \n Eighty phone calls is absurd. It illustrates exactly why consumers feel helpless against large insurance companies. Thank you for stepping in to help this patient when the system failed.<\/p>\n
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