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BlueCross BlueShield North Carolina: Keep your end of the deal and pay the claims

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My daughter needs IV treatment each month to fight a debilitating and life threatening auto-immune disease called Dermatomyositis. BlueCross BlueShield of North Carolina is denying claims for vital treatment. When you pay your insurance premiums and do what you are supposed to do, the insurance company should do their part and pay for the appropriate treatment. Instead, when we called the BlueCross BlueShield to get approval for her life-saving treatment, BlueCross told me and the hospital that that we didn't need pre-authorization. Then, they changed their mind and now want my family to pay a bill of $240,000. 

Since the CEO just got a $1.6 MILLION bonus for 2012 from revenues of $5.7 Billion, it doesn't appear that costs are a concern. Patrick Getson, a VP, got a $232,788 BONUS for 2012. Please sign my petition to tell BlueCross that they need to do their part and live up to their responsibilities to us as subscribers to their policy. We did what we were supposed to do, and they need to do what they are supposed to do and pay for these claims.

Here is what happened...

My daughter Morgan has been fighting a rare autoimmune disease for almost 3 years. She was diagnosed at age 11, and she went from being a tremendous athlete to being unable to ride her bike, walk up the stairs, or play sports. After over a year of trying to find an answer to the problems, we finally got a diagnosis of Juvenile Dermatomyositis, a rare auto-immune disease that affects the skin, muscles, and the vascular system which causes problems all over the body like joint pain, severe headaches, GI issues, and sometimes heart and lung issues as well. Since she was diagnosed, we have known several children who have died from this disease, and we have done everything we can to make sure that she is getting the correct treatment.

The very first thing we did is to make sure we had adequate insurance coverage. We already had great insurance, and we backed that up by increasing the amount we put into HSA accounts. We found the right health care experts as this is a rare disease and not many peopole know much about it or how to treat it. We followed treatment recommendations to the letter and we learned as much as we could about the disease. We modified our entire life behavior to help reduce the chances of her disease getting worse by doing things like staying out of the sun and skipping pool and beach trips because the sun makes her disease worse.  As she was treated, the first line treatments weren't helping and she was getting worse. The doctors said that she needed to be admitted to get the second line treatment. Once again, we did what we were supposed to do, and we made sure the hospital called the insurance for authorization. Each and every month, the hospital called and spoke to BlueCross of North Carolina on the phone. Each month, they told the hospital that authorization was not required. 

The second line treatment is an infusion called Introvenous Immunoglobin (IVIG). This medication has been like a gift from God and it has made a HUGE impact on her disease. She gets it every four weeks, and we can always tell when it is close to the time to go back as she starts getting worse again. As soon as she gets the treatment, we see improvement again. It is not a fun treatment for her to get. She has to be in the hospital, has to get an IV inserted, is woken up ever hour during the night to be sure her vitals are stable, and she suffers extreme headaches after it. But, she gladly goes without complaining because she knows it helps her.

BlueCross paid some of the claims for her treatment and denied others. The hopsital was confused as they had followed the same authorization process and billed them exactly the same way. They tried appealing them first without even telling me what was going on. By the time I knew they were appealing these odd ones, BC had then denied many, many more items. I called them thinking it was just some weird mistake since it was approved one month, denied the next, approved the following. They said that a person had reviewed the ones that were denied and a machine had approved the ones that had been approved.

I have formally appealed their decision based on the fact that the hospital called for authorization each time and was told it wasn't required. They have denied the appeal saying that it has been their policy since 2010 that it requires authorization and that the fact that we didn't know that isn't their fault as it was buried in their policies. This makes absolutely NO sense since we DID try to get authorization. How do you get authorization if you are told you don't need it when you ask for it?

I have already spent countless hours on this appeals process and many sleepless nights worrying about being bankrupted by this $240,000 bill. Additionally, I worry about how she is going to get the treatment in the future as I am still having some issues with approvals even now that we DID finally get them to write an authorization for a year. Just getting that letter required talking to many people and demanding it as they kept telling us it wasn't required.

Thanks for your support, and I wish you and your family good health. All of the sudden, we were thrown into this health care mess the day she was diagnosied. We need to hold insurance companies accountable. Unfortunately, from talking to others, this type of experience is far too common.

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