Advice From a Patient Living in California with Blue Shield PPO Insurance

I have had some grief and it has taken a long time to be reimbursed by my insurance company, but it was worth it - I got reimbursed for nearly all my expenses. Here is some advice that might help you.
[This is advice was submitted by a patient, based on individual experience and may not be the best advice for all patients.]

1. Send in the information early. The longer you wait, the more you will lose track of what is going on. The problem is that you are submitting multiple claims and your insurance company will split it up. You may get a few letters from your insurance company just from one office visit. It becomes very difficult to track. If I had done this sooner, it would have become easier.
2. Make sure you send any and all forms. Make sure that you complete the forms fully. Any omission of information will slow the process. They may require lab results. They may require physicians notes. The more information the better.
3. Get to know someone who works at your insurance company and be polite.
4. Have them sign for the mail you send them. Certified mail is very important. Insurance companies are notorious for "losing" paperwork and telling you it never arrived.
5. Don't fax them anything, they may complain its illegible and they often claim it was "never received".
6. Once the initial claims are sent, you may start to receive rejection notices with ambiguous requests for more information. You may have to work with someone over the phone and possibly the IBS Treatment Center to find out what is needed. Often times, you will receive the wrong advice from your insurance company. Over the phone, an insurance company representative might say, "Oh, all you have to do is X and you will be reimbursed." Take careful notes with date and time recorded to use later. You can use this bad advice later in the complaint letter if you need to. They may also say, "We don't reimburse for that." Often times this is incorrect too.
7. I personally pointed out why the IBS Treatment Center was a unique facility. I more or less told them, "The IBS Treatment Center is a unique facility only found in Seattle. Dr. Wangen has a best selling book on IBS. My in network providers said going there was a good idea."
8. Instruct them to deal solely with you and not The IBS Treatment Center. They will still send information to the IBS Treatment Center to further complicate matters. Often you will be waiting for a mailed response made personally to you not knowing that they sent it to the IBS Treatment Center. (The IBS Treatment Center will usually send things on to you, but it may take an extra week, given the mail).
9. Tell them to be specific as to what is necessary to submit the claim. They may say that the information is incomplete but not tell you why.
10. When things fail, you can file a complaint with the state. You can google and call the state to get information on this. But, before you do that, you should file a complaint directly with the insurance company. There are forms on the health insurance website. In the state of California, I was required to do so first. Simply filing the complaint with Blue Cross was enough for me. This was when I started getting paid back. Don't be bashful or demoralized by what they tell you. Move the process along. The IBS Treatment Center and the Center for Food Allergies are cutting edge science and is not some hippie medicine dealing with chakras. This is your money and not theirs.
11. When filing a complaint with the insurance company you may consider sending it in as a batch if you think its a more efficient process for you and for them. Why fill out 5 insurance forms when you can just fill out one and put everything in one form. Also, keep a copy of what you sent.
12. Access the insurance company's website for timely and orderly details as to what's going on and to get proper forms.
13. Here are some ways they short-change you. They may try to short change you on the reimbursements for more thorough allergy tests because more food allergies are being tested. They may try and short change you on the fact that you are purchasing office visits that have not been incurred on the date of service (if you buy a package, as I did). They may tell you that it's out of state and therefore its not covered. They may say that they only provide $3 for taking blood, when we all know it would be unsafe at those prices. They may say that the procedures are not proven and therefore not provided. They may mistake procedure codes and input the wrong codes. Explain it.
14. You cannot email them anything. They don't have email addresses. You will have problems reaching specific people you have talked to in the past because they are on the phone. Avoid waiting for them and speak to the available agent.
15. Dealing with an out of network provider can be a slow process. Its not simple like using an in-network provider. The insurance company is a business that wants to make money. Don't lose faith even though you are sick and it makes everything worse. They will likely pay and when they do they include interest.