Author Topic: Take Back  (Read 4186 times)

mcmsouth

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Take Back
« on: September 23, 2014, 03:45:19 PM »
Blue Cross of Georgia is issuing a "takeback" on a patient for all of 2013 to current (patient seen once a week for 1 yr, 9 months.)  Called and the said that the policy does not pay for LPC's, which is my provider.  In the verification of insurance on the website, it does not list any exclusions.  This is a group and they are withholding monies for all providers under the EIN.  Is there any recourse to handle this with the insurance company?

Could you go back to the patient for the new rate adjustment?

PMRNC

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Re: Take Back
« Reply #1 on: September 23, 2014, 04:17:52 PM »
First, is this an ERISA plan?
The answer could be yes they can take it back, but the appeal process is different for ERISA vs. Non ERISA, and yes the patient can be billed.
Linda Walker
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mcmsouth

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Re: Take Back
« Reply #2 on: September 23, 2014, 05:34:27 PM »
No, it is not an ERISA plan, but a regular health insurance plan.  So, you say can appeal. On what grounds, non disclosure of information?

PMRNC

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Re: Take Back
« Reply #3 on: September 23, 2014, 06:57:24 PM »
So I'm taking it that this is either a govt/state plan OR church? When you say a "regular health insurance plan" it's either state/govt plan which is ran through state dept of insurance, any other plan is ERISA plan which is dept of labor, for ERISA claims you can get the benefit summary plan information from the member as a courtesy to them and appeal it as long as it's not in the plan benefit booklet. Insurance carriers quote their disclaimer when verifying benefits that it is not a guarantee of coverage. Now if the licensure of the provider in the state services were rendered is not covered, you can try and have nothing to really lose but I wouldn't hold your breath. You can TECHNICALLY bill the patient because it is their job to go to covered provider ..however that can get sticky too with a regular patient since they have been going there weekly. You might get further by having the patient call them up to gripe <g>
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

rdmoore2003

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Re: Take Back
« Reply #4 on: September 24, 2014, 05:38:32 PM »
  In the verification of insurance on the website, it does not list any exclusions.


When you looked on website for verification, did you look at just exclusions?  Generally, you look under Provider Types as well to see which providers are covered. (at least in my state we have that option)

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Re: Take Back
« Reply #4 on: September 24, 2014, 05:38:32 PM »

PMRNC

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Re: Take Back
« Reply #5 on: September 24, 2014, 05:58:58 PM »
Quote
When you looked on website for verification, did you look at just exclusions?  Generally, you look under Provider Types as well to see which providers are covered. (at least in my state we have that option)

Certain "state" exclusions are not going to be in benefit booklets or when verifying benefits. The scope of a providers license is something on the "state" level, has no baring on the policy or carrier. If some carriers do have it ..it's a bonus but it's not required.
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

shanbull

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Re: Take Back
« Reply #6 on: October 09, 2014, 01:54:38 PM »
Here we are not covered by insurance verifications via the insurer's websites, there is a cover-our-butts disclaimer on most of them saying something like, "the benefits quoted online should not be used as a guarantee of reimbursement and should not be communicated to the patient, please call us for specific coverage inquiries." Does your verification site say something similar?

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Re: Take Back
« Reply #6 on: October 09, 2014, 01:54:38 PM »