Ex-Husband / Privacy / Timely Billing

[Funkymark]

I am trying to help out my new girlfriend.

Ex-Husband broke into her car (7-4-2009) and took the Heath insurance card Drivers License, and SSN card.

A month later she needed medical care in a town 4 hours away at Hospital ABC.

At time of service (8-2-2009), she was covered under her husbands (now Ex-Husband) heath plan.

She informed the Hospital ABC that provided the medical services that she was cover by her husbands plan but did not know the plan number.

After being discharged, she went to husband employer, (the City) to get the ID number, but since they were going through a legal separation, the City would would NOT provide the ID number.

She tried to get the number from her local hospital, since they had it scanned, and were paying claims, but they refused to provide the ID number also, for privacy issues since the Ex-Husband was the primary policy owner.

All the insurance EOB's were being sent to the Ex-husband since he changed the address for the plan communications.

By the time she was able to provide the ID Number to Hospital ABC, the time to for Hospital ABC to file the claim had passed and Hospital ABC did not submit the claim, and Hospital ABC sent her to collections and a judgment was issued that she must pay the entire amount.  Her wages are being garnished.

A month after the judgment was issued I got involved.  I got the UB form from Hospital ABC billing supervisor and submitted it to the Insurance provider which processed the claim (9-15-2011). 

The insurance provider EOB says the patient responsibility is $0.00.  Claim was not submitted timely based on the contract between the Hospital ABC and the insurance provider.

In the Insurance Company EOB message it says " This service was submitted for payment after the claim filing time limit. The member is NOT responsible for this amount." (which was the entire amount of the claim)

She did provide Hospital ABC the ID number as soon as she possibly could.

She was sued for the entire amount of the bill and lost and has a judgment to pay the entire amount.

She is an honorable person, and wants to pay her fair share, but not the entire bill.

Thank you in advance for you assistance.

[SLITTLES]

This is such an unfortunate case that I have seen happen often just not to this extent.  From the hospital's point of view, they could not file the claim within the timely filing limits because they were not given the proper information to file the claim so it's her responsibility to pay.  Did she explain her situation to them because it's not that hard to get an ID number once you have other identifying information? I'm not sure what can be done at this point since it has been adjudicated in court but has she tried to negotiate only to pay a portion of the bill considering the circumstances???

[rdmoore2003]

she could try to appeal with the insurance company and explain to them the circumstances.   Does she have proof that the ex stole her belongings and if so was there a police report filed?   I have also had a similar issue (not to this extent) with a patient, but it was theft by a coworker and due to police report her insurance was appealed and she won the case about 2 years later. 

[Funkymark]

She did provide the ID Number verbally on (4-2010).  The Hospital ABC did not submit the claim to the insurance provider.  The first claim to insurance was (9-15-2011) when I got the UB form from the Hospital Billing.  The hospital billing supervisor said she would not submit the claim from her end as she "did not want to have to write this bill off."

No police report was filed on the car break in. No cash, No wallet, CD's, or Stereo's we taken.  Only Drivers License, Insurance ID Card, and SSN.  Only things to make her life difficult. The Ex-Husband (an on duty cop at the time) did plead guilty to Misdemeanor Vandalism (her car) and Unlawful disclosure of Dept. of Motor Vechile records (hers also).

We spoke to the insurance company and we told she owes NOTHING to the hospital, and the EOB says her responsibility is zero.

The insurance company also said that since they have a contract with Hospital ABC, that if they try to get her to pay, they are "Double Dipping" and volating the contract they have with the Hospital ABC.

The insurance company said the Hospital should have used "reasonable and customary" procedures to get her Insurance ID number since she was not able to.

This is very frustrating.

Again, thank you all for any thoughts and advice.

[rdmoore2003]

It seems that if she gave a verbal insurance id# that facility should have billed the claim.  If the insurance company is on her side, then she really needs to fight this all the way, especially if she can prove that she did give them an id# etc.   in my state, some instances like her wages being garnished, they must repay with interest..... good luck

[DMK]

Maybe I'm not clear on this, but if the insurance company DID receive and process a claim, then the hospital HAD the information and DID submit a claim. 

If she provided the info timely (but 8/09 to 4/10 is a long time to not have provided information), and the hospital just failed to file the claim timely (and the definition of timely will be different for each insurance company, but for many it's 90 days) then she should be able to have the insurance company back her. 

If she has proof of when she provided the information that will stand up in small claims court.  The facility will have to prove that she did NOT provide the information when she says she did.

My biggest question is why did it take her 8 months to get her own insurance benefits information?  I can usually get people's insurance information with their date of birth and social.  Why was this case so difficult?

[Funkymark]

She was going through a very public domestic dispute (Her husband was a Cop and was charged with many felony charges against him), it was in the papers, on TV.  All the insurance was under Him and His employer (City Police Dept). They were going through a very public Legal Separation and know one would provide her the Insurance ID number, saying it was a "Privacy" issue.

There were domestic violence issues, restraining orders, and fear for her life. And the Ex-Husband refused to provide the Insurance ID to her.  The only reason she got it on 4-2010, was their son broke his arm and the hospital needed the number, and the Ex provided it to her then.

When she go the Insurance ID that day, she called Hospital ABC with the ID number, but since it was out of their time to bill, Hospital ABC had already turned her over to a Collections Company.

She did provide the Insurance ID number (4-2010) to the Hospital, After the Timely Billing period, should they still have submitted the claim?

The insurance company only processed the claim after I got involved (9-2011).  The hospital Billing Supervisor said she would not submit the claim because she did not want to write off the charges.  The Billing Supervisor said that WE could submit a UB form to the insurance company, and the insurance company should pay the claim.  She would not mail the UB form to us, we drove for 6 hours to pick it up.

She is a single mom with 4 kids, working one full-time job, and just took up a part-time job to pay this medical judgment.  And her Ex-husband is paying Zero in child support.

I'm doing my best to help with this one past issue.
Thank you

[DMK]

So sorry for this lady's troubles!  The insurance company should back her up though, she was a covered member at the time of the claim.  With these extenuating circumstances the insurance company should "man up" and pay the claim, even though it fell out of timely filing.  I would appeal to the highest possible level on behalf of the patient. A few well placed phone calls (you'll be on hold for awhile!) to the appeals department, and then your state's insurance commissioner wouldn't hurt.

JMO the hospital biller is being a stinker, but they do have their guidelines they have to follow, and their hands may be tied. 

The patient will have to advocate for herself (or with your help) to the insurance company.  Even the most heartless companies should be understanding in this circumstance.  I would not, however, wait very long to really jump on it.

[Michele]

I agree with DMK.  She should appeal the timely filing stating all of the facts that you have given us.  She did everything in her power to try to provide the information to the hospital and to assist in getting the claim filed appropriately.  The hospital may have had the means to get the id# as well.  If they had the patients name, dob, ss# and other personal identifying info, the insurance carrier should have been able to locate the patient and provide the id#.  I don't know why it had to go this far.

[PMRNC]

First I say this is a highly legal issue that needs the attention of an attorney first and foremost

A few strikes I see here is that there was no police report on the stolen ID, etc..  the fact that a "Judgement" was issued by hospital tells me this has already seen it's legal eyes and the fact that there is a garnishment in place also says this is being followed properly.. THAT is why I strongly recommend a lawyer to appeal the judgement and stop garnishment.. why wasn't this done at time judgement was pending (before issue, and well before garnishment) There had to be proper notification of the judgement and then of the garnishment before hand..that was the time to strike, but I know you are coming into this late. 

Another thing.. while we might all think the ID number was not a private issue..that's not true.. Some states prohibit the use of SSN for this very reason, it does NOT go by the state of the employer it goes by the state of the underwriting issuer of the policy. It's not cut/dry since this is a city employee. You can't assume it's THAT city/state where the policy was underwritten. 

Bottom line is there has to be legal representation because there is a judgement and garnishment in place and a lawyer is the best person to go around this and well..practically speaking if a judgement and garnishment is already in place..there's no longer any basis of appeal until the judgement is settled and then you can try and recover AFTER to recoup.