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Blue Cross of Illinois

Donelle of Chicago IL (05/09/08)
My husband has BCBS of Illinois PPO. Encompass Health Management Systems is contracted to work with my husband's place of employment to pre certify occupational and speech therapy. When I went on the website for my husband's medical insurance in the Dept. of Human Resources, the speech therapy and occupational therapy is listed as paying at 90% in network coverage as long as it is pre certified by Encompass Health Management Systems.

Our 4 year old son has sensory modulation issues, auditory processing, vestibular, oral sensitivity, tactile, inattention issues all with his sensory processing disorder. He has some coordination difficulties as well-that can occur with sensory processing disorder. We went to our pediatrician whom gave us the referral we needed to get an evaluation from an occupational therapist to help with the sensory issues in question. This is needed to get the evaluation itself as well as for the insurance company for coverage. We obtained that from our pediatrician and went to Children's Memorial occupational therapy dept. on April 22, 2008. We found out our 4 year old son needs occupational therapy once a week for one hour. Our insurance information was sent in and Encompass was notified that our son would be needing this therapy one time a week.

We received a letter from Encompass Health Management Systems around May 4th or so dated April 29th, 2008. Encompass is denying any and all precertification necessary for BCBS to pay for our son's therapy he needs. Their reason is, Encompass has been uanble to certify the Occupational Therapy service because services are for acquisition of function normally expected for your child's developmental age. If our son was completely up to developmentally what he should be then we would not need the occupational therapy once a week for an hour a day. We are not looking for a hand out. We are just looking for the occupational therapy service once a week for our son. My husband pays into his plan. The money is deducted from his paycheck and we are not trying to take advantage. We just want help for our son.

On May 8th 2008 I called Encompass to tell them I was going to be filing complaints with the BBB and anyone else that would listen about the unfair practice of denying needed coverage for children. I talked to a woman named Penny after waiting for around 25 minutes for the receptionist or person answering the main calls to find a supervisor. I could hear someone pick up the phone and place me back on hold as if to see if I was still on hold. Anyway, I stated my case to Penny and wanted to know the name specifically of the person Encompass was claiming was telling them from my husband's place of employment to deny precertification for our son's therapy. She could not come up with a name but stated in our benefits handbook it would probably be why our insurance pre cert was being denied. I told her I was on the main website that stated 90% coverage for in network as long as Encompass Health Management pre certified the therapy.

I wanted to at least know what page this denial is supposedly under in the benefit book and the name of an actual person in charge of the denial of pre certification. Penny told me the supervisor in charge of that information was out and would not be back for a few days.-This was 5/08/2008 that I spoke to Encompass. Shetold me she could resubmit it for review. We have the letter from Encompass giving us the ridiculous reason for not precertifying our 4 year old's coverage is because services are for acquisition of function normally expected for your child's developmental age-as previously mentioned. The whole reason for the occupational therapy is to help our son acquire function normally expected for his developmental age. It is only for one hour a week once a week-nothing extra or fancy.

I am upset that the precertification may be denied again for therapy my child really needs from insurance we pay into. We are a middle class family that does not qualify for low income special state funded programs. We rely on our insurance coverage to help us for reasonable expenses. We think that therapy for our son once a week is a reasonable expense. I am sending info. about this off to the Tribune editorial section, state legislators and anyone who will listen to try to be an advocate for my son and other families who are being abused by health management systems and health insurance companies. I just wanted to get the word out through your website as well.

These companies are hoping when we receive the denial of coverage letters that we as the ins. consumer will accept this and not file a complaint or follow up on the denial. We are our children's best advocate and we have to fight for them against unfair insurance policies and the health management system companies they use for pre certification like Encompass. Please just help me get the word out about unfair denial of ins. coverage for our kids.

We have brought our son to 2 sessions so far at Children's Memorial Hospital and have paid over 500.00 so far for 2 hours. This is our rebate check money. After that is gone we will have to use money that would have gone to bills. I discussed filing bankruptcywith my husband. We have looked into Easter Seals but it still would be around 600.00 a month. I am not able to take a job at this time or I would. We have a mortgage and other bills but would forego having our condo if it meant we could pay for our son's therapy. We aren't asking for the moon so to speak just for 1 hour of occupational therapy once a week to help our son. Our last hope is for Encompass to pre certify treatment for our son's o.t. therapy. We are at their mercy with this.

Maryann of Sioux City IA (04/16/08)
I have had several medical bills denied due to a lack of information that was sent several times. The fact of the matter is that there have been too many incidents to keep track of. I do have information, but it would take forever to find all of it. One incident in particular, is an incident that involved services rendered on 1-17-07 from CNOS (Center for Neurosciences, orthopaedics, and Spine)PO Box 1430 Dakota Dunes, SD 57049. My primary contact at CNOS is Sue. It has taken us over 15 months to get this paid. BCBS kept telling me different things, then kept telling her different things. The last instances they were telling her they needed me to send the dates that I was under United Health Care. They kept telling me that they needed her to send the EOB (Explanation of Benefits) from United Healthcare--United Plan # and BCBS # available upon request (I don't like over the internet information transfer) BCBS Address Via National Automatic Sprinker Industry is 8000 Corporate Dr Landover, MD 20785 - 800-638-2603 or 301-577-1700---United Healthcare PO Box 740800 Atlanta, GA 3037 40800 Ph#800-357-0978.

Today we spoke with Sadequa Via 3 Way Calling. Her Ext at BCBS is 4789. She stated that she needed the EOB from United and that she had a wrong address for CNOS. The address she had was a physical address and would have still reached the same place. CNOS did receive the denials so this is not an issue. Just in case though, Sue @ CNOS faxed a new W9 and the EOB while keeping her on the line. At first, she stated that nothing was received then after persistance, we tried again and to 2 different fax #'s. Eventually, she stated that she received the information. If it is not taken care of this time, what should I do. ALSO, this is not the first time that a 3 Way call had to be used to get things taken care of. The last time, they also said they did not receive the faxed info the first time and we had to fax it again. Needless to say, I have not been happy about this.

My husband works for a Union though. They choose who our healthcare is through and we don't even have a choice that allows us to opt out and just receive the money they take per hour for this. If we did we would have taken the money and paid for a different provider years ago. This would not be as frustrating if we didn't get a different story every time we called on the same issue. The first 4 or 5 times, they told me a different story on what they needed everytime. Call me if you need more info. Sue also said she would help in any way possible. P.S. I don't want to put BCBS out of business. I just want them to do things correctly. Preferrably the first time the claim is sent, then I don't even have to get on the phone and waist hours of valuable time!

Several hours of lost time. Possibly a dent in my credit history. If you want to split hairs, increased stress which leads to increased headaches and pains. Which leads to increased cost for pain medication. Which leads to financial troubles. Etc.

Robert Bonem of Los Angeles CA (03/20/07)
I do not recommend Blue Cross/Blue Shield of Illinois. When I filed a claim, they claimed there was a paperwork error, even though I had proof to the contrary. Now I have cancelled my policy, and again they are claiming a paperwork error, and continued to charge my account.

Several hundred dollars lost plus a lot of time and aggravation.

Susan of Prospect Heights IL (01/05/07)
I received a letter of my bimonthly premium going up and I have only had this plan since July.It went up 32.00. I only make 28,000 per year. I am now paying 332.00 every 2 months. These people are out of control, and have been for years.

Vadim of Park Ridge IL (03/26/06)
Hello, Blue Cross Blue Shield of Illinois sent me a letter informing that they are investigating my medical claim, suspecting it was preexisting condition. Fine, it's their right. But one sentence in the letter attracted my attention: "until the investigation is complete, all future claims will be pending."

I called and asked why. If the future claims are unrelated to the investigated one, why they would be delayed as well? The rep in claims explained the situation quite honestly. According to her, they do it in order to force me to cooperate and give them the information they want as soon as possible, plus they hope that I would also call the doctor's office, who is expected to give them medical records, and ask to expedite.

She also mentioned that if the policy was for 10 people, then all 10s' claims would be put on hold, also with the expectation that nine would press on the one under investigation. I asked if she thinks this could be named blackmailing. She easily agreed. She did not express any shadow of regret, however.

Patrick of Cicero IL (12/12/03)
i called for a brochure to inquire about health insurance with the above named company and received it.i comply with all the parameters set forth in the brochure including the heaight and weight chart that states a male person of my height can weigh up to 305 pounds, per the brochure sent to me.i also qualify under the section that asks if you are presently being treated for diabetes,which i am not.i have an elevated blood sugar that i am treating with diet.in other words, according to the brochure sent to me i qualify for health insurance.now KAREN G,WHO IS SITTING BEHIND A DESK,is making judgements contrary to what is in the guidelines that were sent to me.

Carolyn of Antioch IL (06/24/03)
In July, 1999 I had been working for Pepsi Cola General Bottlers, Rolling Meadows for about 3 months. Was new to the insurance and new to the company, in fact I hadn't received an insurance card yet. I was at a company sponsored event at a water park, I received a head injury when I smashed into a cement wall. I was taken away in an ambulance.

The next morning I called the primary care doctor I had chosen, in fact I contacted every primary care physician in the Antioch area to make sure I alerted them to the incident. When HMO received their paperwork on me, they claim they never received the form which lists out my doctors name. So they arbitrarily assigned me to a doctor in another town. Of course according to their records I didn't call and receive a referral from my primary care physician. So they have been denied the charges.

In January of 2002 it was brought to my attention that the charges were outstanding still. I contacted HMO and talked with a Sarah Morgan who assured me that this would be taken care of. She was in contact with the collection companies and they were going to send her whatever statements were needed to clear this up. I never heard from anyone after that and the charges were dropped from my credit report.

In April 10th this year my credit was pulled and it was not listed, the bank I'm attempting to refinance with pulled a subsequent report and the charges were brought back up again. To find out that the charges still have not been paid. I contacted HMO and spoke with consumer affairs who is now disputing that the incident was indeed an emergency.

The economic damage is that this incident has been on my credit off and on for over 4 years now. I was fully insurred at the time and these bill should have been paid. I'm at this time unable to take full advantage of the low interest rates because now I won't be able to refinance for at least another 60 - 90 days which is what I was told was suppose to be the soonest timeframe.

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