BCBS EOB and payment issue out of state labs/doctor
I will try to make this short – In 2020, due to covid, I got effectively “stuck” in Puerto Rico area as I was working out of state. Several health issues happening I had to utilize telemedicine and a local lab. The local lab was in network according to my plan. Every visit they would call to verify what my copay was that day and I paid it. Fast forward 4 years and I continued to use that lab any time working in the area if I needed labs from my home doctor. In 2024 I got two denied claims as BCBS of PR stated they were out of network since the doctor is in a different state. I argued they had been paying these claims all along and attempting to get re-evaluated and escalated.
Fast forward – on the phone with the lab and BCBS TX/IL and the lab stated they “just realized” BCBS of PR has been rejecting claims all along! BCBS of TX/IL has NO record of these claims. BCBS of PR was never submitting to the home plan. The lab never followed up with BCBS or myself and never generated or sent me any bills. The lab never informed me on any visits that there was no ins payments being made and there may be outstanding bills. Every time I visited over the years I inquired about outstanding bills and they said there were not any listed on my account. BCBS never sent and EOB to me and they do not exist in my portal. This is thousands of dollars since 2020.
If I never received a bill AND BCBS did not notify me of the denial reason, I had no chance to appeal. I would have appealed, or stopped using the lab or found a local PR doctor to order the labs. Considering residents in both Puerto Rico and USVI must travel back to the US for services it is very common to have stateside doctors ordering labs and medicines.
My question – are there any laws on insurance companies providing EOB’s? Especially for denial of services. How can they deny services and NEVER send or post an EOB in my account? As I said, my local BCBS of TX/IL has no record of receiving anything from BCBS Puerto Rico – they have zero record of any of these visits.
