First off, let me get my perspective on the healthcare system in the US out of the way: it is abysmal. It is a pity that so many in this country are misinformed, and think that a for profit system can ever benefit the patient. It is an impossibility, a paradox. In its very essence that company which does what is best for the patient will go out of business as their customers will be healthy and not need service. It really is that simple. So I am completely not surprised the following happens...
I have full insurance for this, probably some of the best plans left in the country since it is one of the few remaining benefits of a quickly declining union. However, there has yet been a single visit, claim, or procedure that did not produce a mountain of paperwork, or require lengthy menu navigations to get to a human being who fails to fix the problem the 5th time you speak with them (or so it seems that way). Horizon BC/BS- F YOU. And that is my professional opinion.
Apparently because the hospital did not submit some progress notes in a timely manner they are denying the claim, and they will have to submit again. Being an RN I know people who work in the insurance side, and there is one thing I know for certain--this like many other letters that get sent, are done so on purpose and without real merit. ALL initial claims are ALWAYS denied. Studies show that is the first line of defense against payment and guarantees more profit. While there maybe one or two companies out there that do not practice this, this has been my experience. While they will eventually pay since everything was cleared, my bet is it will take the better part of a year for things to be settled. I mean really, do you need a progress note to justify a 3 day hospital stay for a patient who had two surgeries on the same day of this magnitude...there is 0 justification here, just profit motives.
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