Reimbursement of Benefits Paid due to Clerical Error

[smokingtundra]

My question involves insurance law for the state of: Alaska

I am a member in the Federal Employee Blue Cross/Blue Shield basic plan. In 2011, my 15 year old son was having a rough time, and was in need of psychiatric therapy. My wife was able to locate a provider who has a great reputation with teens, and who was able to schedule an appointment to see him promptly (which is also hard to come by in our town). Our plan pays no benefits for non-preferred providers, unless an exception is pre-approved, usually if there are no other preferred providers in the area. Even though he wasn't a preferred provider, the doctor suggested an initial assessment and intervention session, which we figured was worth it for us, even if we had to pay out of pocket. Surprisingly, insurance paid in full (minus the $25 co-payment). We continued to see the provider for the rest of 2011, and insurance continued to pay in full.

In 2012, they stopped paying, saying our doctor wasn't a preferred provider. After several non payments, I called the company to have them look into why, as our plan had not changed, nor had the status of the provider. Turns out is was a clerical error on their part, and they sent a bill for reimbursement of all payments made (in 2011) to the our doctor, and said it was between him and us to figure out who pays. Now we're stuck with a reimbursement bill for over $2000 on top of the $900 for the 2012 expenses (which we paid in full). Had we known insurance wasn't going to pay, I'm sure we would have looked at switching providers or stopped going. Anyone think we have a chance at appealing this one?

Sorry to be so long winded and thanks for any input,
Mike.

[cbg]

Not unless you can show evidence that you were told, by BCBS, that he WAS a preferred provider. It is your responsibility to determine, ahead of time, who is and is not covered by your insurance.