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ANTHEM, AŞ Message Board

  • bgr912 bgr912 Dec 19, 2012 7:17 PM Flag

    WLP denies claims as a starting point

    I had a pre-certification of benefits done by WLP and they approved the procedure for payment and then I had the procedure performed and the claim was denied anyway. I think WLP is likely denying many claims on the front end just to see what happens find out if people will appeal.,. I am a retiree from WLP having worked there for 35 years and I never could have imagined they would have become so desperate that they would stoop to such tactics!

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    • A pre-cert is not a guarantee of payment. When WLP sent you their approval for the procedure, they told you that.

      Most of the time, a covered service that has been pre-certified will be reimbursed. However, in some cases, a claim can be denied even after pre-certification - and there are good reasons for that.

      You have not given enough information for anyone to know what really happened in your case - whether the denial was correct, or whether WLP made a mistake.

      For example, you did not share the denial reason WLP gave you. It's stated on your explanation of benefits.

      • 4 Replies to fembup
      • For FEMBUP --- you said. "bgr412 after you revealed what your dental procedure was, I clearly said that I thought WLP “simply bungled” your claim. In what way do you disagree,"

        First I disagree because you never said you thought WLP simply bungled the claim. Find that in your commentary you idiot. You just made that one up. Yes, Is said I worked for WLP for 35 years, meaning the BCBS system for 35 years. As far as responding to your so called facts you made statements such as I no longer might be insured. You were simply grasping at straws to support the WLP denial, which was wrong.

        I do believe that you do need to re-educate yourself on the health insurance before you wrongly criticize others. A pre-certification under ordinary circumstances means the impending procedure will be paid if performed as pre-certified, which it was in my case. So I think maybe you need to get a better understanding of what a pre-certification means. I had to expalin that one for you, you did not prompt anyone.

        FEMBUP you made the following commentary "Fails to respond to the facts and rationale I presented about first-pass claim resolution rates – leaving your belief in the urban legend totally unsupported" FEMBUP You never presented any facts you made assumptions about why the claim was incorrectly denied in the first place, with no real basis for your assertions.

        The claim has now been paid. Wrong again FEMBUP

      • Claim now paid and WLP screwed up in the first place, just a lot of hassle for no reason.

      • FEMBUP -- a few comments. There were 2 line items on the claim as it was gum graph surgery for 2 teeth. The EOB denied one line item because the charge exceeded the allowable charge, which you of course know is not a valid denial reason. The allowable charge reflected on the EOB was for 0.00, with a patient responsibility of the full amount of charges. As you know most claims exceed the allowable charge and difference is a provider agreement write-off. The second line item provided no reason whatsoever and reflected patient responsibility of the full amount of charges.

        As a result of subsequent contacts with WLP by me and my dental office indicates that WLP has admitted error and the claim should have never been denied. As I stated in my first post I worked for ATH/WLP for 35 years and full well understand that a pre-cert is not a guarantee of benefits, but unless there are unusual extenutating circumstances it does usually mean payment.

        Who knows if they will ever handle correctly without much ado from me, but after working in the industry for 35 years I know a mistake such as this when I see it and I re-iterate that I believe WLP is purposefully denying claims on the front-end,because of the turmoil the company is in.

        I retired from WLP a few years ago and have seen a deterioration of service and quality first hand. I also was aware of the problems in the dental area in my latter years at WLP.

      • Well fembup. Before you ask this person to give away their PHI (personal health information) why don't you give everyone here an example of a "good reason" to reverse a decision to pay a claim? Why would it look good initially and not so good afterwards?

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