Florida Blue review: Claims appeal process

Florida Blue provides an appeal process that borders on unethical disallowing any direct contact between the patient and the Florida Blue Appeal reviewers requiring the provider of the services to directly contact the insurance company for details. In theory, this process may actually be effective some of the time, except when laboratory services are administered by a third party (AKA, the provider) as required. Case in point, Florida Blue healthcare insurance when associated with affordable care act mandates the use of quest diagnostics to perform laboratory work in Florida. Certain procedures are covered under unique circumstances but considered investigational under other circumstances. Florida Blue routinely denies the claim and it is up to the patient to coordinate between the physician who ordered the service (yet has no direct financial stake) and the provider (laboratory) who actually gets more money when the service is denied to provide the unique language and background needed for claim coverage. The third party (Quest Diagnostics) has no incentive to get it right and Florida Blue has no incentive to get it right and the physician has no direct financial benefit to get it right and Florida Blue provides no direct access between the patient and the Florida Blue appeal process. Hence, months go by and no one gets it right until Florida Blue passes the amount of time where they have to pay the claim and the patient is then required to pay the denied claim. Whether this is unethical is certainly up for discussion, but it is certainly unfair. For my particular case, a scan was performed 5 times over an 18 month period, denied each time and eventually covered through appeal after months and numerous calls, chats, and back and forth conversations between the physician, Florida Blue, and me. The sixth time, Florida Blue denied the claim, the appeal, external review and provided no capability for me to speak to someone who could explain what was needed. Keep in mind, this was the same procedure they covered 5 times previously through their appeal process. The cost was only $165, but it is the principle of the matter that is important. Three of the five times, Quest Diagnostics sent the bill to collections before it was eventually covered. The last time where Florida Blue never covered the exact procedure it was sent to collections and I paid the $165 because I was convinced the insurance company was never going to fairly handle the claim. Thankfully, I aged out of the ACA insurance and had other insurance options besides Florida Blue through Medicare and will never have to deal with their unfair / unethical claims process again.