Payments > Insurance Payments

Insurance co./collection co. requested reimbursement for out of network facility

<< < (2/3) > >>

PMRNC:

--- Quote ---I plan to use the city of hope supreme court ruling against them but I need them to back off from our patient.
--- End quote ---

This is why I asked you if this was ERISA plan. With any ERISA plan, the claim is not yours, it's the patient's claim. Unless you had authorization to act on their behalf there isn't much you can do now after the fact. You have several steps and how you proceed depends on the plan. ERISA vs. Non ERISA.   You need an authorization to act on behalf of the patient. You need to check timely filing or the appeals, check recoupment time periods for your state, once that's done you move to the next step which is the appeal. You can't just appeal the refund request, you also have to appeal the actual claim. You have to also see if the patient did anything to appeal this WITHIN the time period given. You will need all correspondence from the insurance company to the patient since you indicated payment(s) sent to the patient not your office.   Your first hurdle is the timely filing. Again as a reminder if this is an ERISA policy it is the patient's claim.

One more thing...you mention the patient was never notified until a year after, that could be within the allowed period and it's also possible the patient was "mistaken"... Before you go all crazy over this, I suggest taking a look at the original claim and the patient's SBP and first seeing if the claim WAS processed incorrectly. I'm not saying that even if the claim was processed incorrectly you still have to pay the money.. as it is right now the patient owes the money but they can decide later to pursue from you.. Remember that you mentioned you were out of network, so let's say the patient was responsible for paying the balance anyway? You have to understand that if this truly was out of network benefit, patient is the claimant, not your office, you may end up with a lot of unnecessary paperwork for a claim that you have technically been paid on. I understand wanting to help the patient, but you have to understand the steps to do so.

Don Self has a great book available to help you with ERISA appeals. www.donself.com    PMRNC also has an area for ERISA in our members only area. www.billerswebsite.com

Game_Of_Billing:
how do I find out if the plan falls under this ERISA set of rules? I was given this old claim by my manager and asked to follow up with the insurance co to have them cease collections on the patient. All of this mess started with Blue Cross claiming price changes for this patient that they claim was applicable at the time of service 6/9/2011. Back in November of 2012 we were informed by the patient BCBS was threatening collections on the patient so we went ahead and contacted BCBS  requesting that they provide our office with manual listing for 2011-2012. We made many requests for this info. All they had provided was a letter of explanation regarding adjustments made. Last we have heard of this was back in May 2013.

Now the collection agency is knocking on the patient's door asking for $22k!

PMRNC:
ERISA plans are employer based health plans non govt or church. With ERISA. If your patient's plan is a group plan not given by state/fed govt or a church, most likely it's ERISA. If it is ERISA, you would need to contact the patient for a copy of their summary of benefits as well as get them to sign an authorization for you to act on their behalf.. since they are going after the patient, there's not much you can do since you didn't have a contract with BCBS (I am deducing that from your prior posts). Bottom line at this particular point is the patient owes the money. You can file an appeal with BCBS on behalf of the patient with appropriate documentation, however if the patient's timely appeal limit is up, there may be nothing YOU can do. The patient can however then proceed with a formal appeal to their human resource dept, union or legal dept. You need two important things here to even move forward.

1) Summary of plan benefits - this will give you all the info on contact, timely filing limits, appeal filing limits and procedures for appeal under ERISA.
2) A copy of ALL EOB's and correspondence the patient or your office received (you may not have these with BCBS even with an AOB if you were non par). You will need to rely on the patient's correspondence and EOB's. Since they are asking for money BACK.. I'm assuming the claim was paid by them, in which case you need THAT EOB to examine any appeal rights (time frame, etc).   With ERISA the patient can also persue legal actions if warranted. (this is on them, though you can't do that).


In your situation it's going to matter when the last correspondence on the claim was.

kristin:
Linda, I have a question, since I have been following this thread with great interest, (and very thankful I have never had to deal with a situation like this, what a nightmare):

When you say that bottom line at this particular point that the patient owes the money, what is the patient supposed to do, since they turned the money over to the provider, and no longer has it?

PMRNC:

--- Quote ---When you say that bottom line at this particular point that the patient owes the money, what is the patient supposed to do, since they turned the money over to the provider, and no longer has it?

--- End quote ---

Well again.. ERISA states this is the patient's claim. I hate to sound like a downer..but it's the patients's responsibility. They had charges with a NON par provider, there is NO contract with the provider and the plan to go with.. this really is a patient appeal.

Navigation

[0] Message Index

[#] Next page

[*] Previous page