5 On Your Side

Five On Your Side Cuts Through Red Tape Over Health Insurance

Posted November 9, 2005 4:57 a.m. EST

— A lot has changed for Robert Prawdzik since he found out he had diabetes last November. Since then, he has lost 60 pounds and now, he is trying to get another weight off his shoulders.

"I'd like to get this resolved and off my back," he said.

The problem is over the cost of a class he took at WakeMed to find out how to manage his diabetes. His insurance, Empire Blue Cross Blue Shield, covers the $752 fee.

"The main part of the class is eating right, not eating a complete bowl of cereal but you do the portions," he said.

Prawdzik noticed a problem when he got the explanation of benefits. The insurance company said WakeMed did not code the class correctly so it did not pay for it.

Prawdzik called WakeMed. He was told the bill would be resubmitted. But then, the hospital sent coupons asking for payment.

"I wouldn't pay with those because the insurance should be paying," he said.

After months of calling, Prawdzik got both his insurance company and the hospital on a conference call.

"They said they would take care of it and talk to the insurance company, and it still hasn't been taken care of," he said.

So, Prawdzik called Five on Your Side, which found out after talking with both Empire Blue Cross Blue Shield and WakeMed that the two companies could not agree on how the charge should have been coded.

After calls from Five On Your Side, Empire Blue Cross Blue Shield said it straightened out Prawdzik's claim and paid WakeMed last month. Hospital officials said they had already "wrote off" the charge before Five On Your Side was involved, but never told Prawdzik.

Prawdzik does not want the same problem to show up somehow later on, so WakeMed agreed to send him a letter saying he does not owe them anything.