Payments > Insurance Payments
Insurance co./collection co. requested reimbursement for out of network facility
Game_Of_Billing:
--- Quote from: PMRNC on July 13, 2015, 10:47:10 PM ---
--- 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.
--- End quote ---
@Kristin- do concider yourself Lucky. Im running into these issues as our facility is a high volume surgical center and unfortunately these insurance companies drop the ball all the time. For the most part we comply when informed timely about a reimbursement provided they send us the necessary documentation to do so. But when they come out the blue demanding payment after years of doing nothing then having some agency attack, this I will not tolerate.
@PMRNC - Wow! I have an uphill battle. We are trying to do what's right for the patient. I have requested any and all documentation, mail/correspondence we have received to be sent to me for review. As soon as I have that and a signed rep/auth. letter I will research what chance if any the patient has to fight this. If the patient is dead in the water I might even suggest to my boss the possibility of negotiating a settlement with the collection agency and or advising the patient to seek legal help.
But now lets take a step back and talk about what first lead me to this Forum and seek help.
The healthnet 40k claim any other advise you can throw my way because this out of network claim HN's collection agency is attacking the facility directly which will hurt the business's credit rating. I had responded with a letter rejecting their claim but they seen to just ignore it.... I used a response from a California firm that points out numerous case laws from different states that favors providers who file claims correctly and are then pursued by Insurance carriers for re-payment. In most all the cases the insurance company is the looser as the provider did nothing to mislead the insurance company and the error fall completely on the insurance provider. I had used a template from a California attorney David Mullens and spoke with the attorney who said we are in a good position to stand our ground but any further advise would be at a price if we decide to hire/have his firm represent us.
Here is the to the template this attorney The law Office Of David D Mullens.
http://www.mullenslawoffice.com/article-justsayno-part1.html
PMRNC:
--- Quote ---HN's collection agency is attacking the facility directly which will hurt the business's credit rating.
--- End quote ---
Ok, but I was under the assumption from your original post that the patient was being pursued for collection? How does this affect the facility? I think I'm a bit confused because in another post you mention BC coming to you for reimbursement?
--- Quote ---About a month after filing the claim the insurance company paid out the full amount of our claim. Now 3 years later I get a call from a Collection agency demanding over 40k in reimbursement given HN does not pay a dime for our out of network facility. They claim we received 3 notices, first notice a month after payment and the other two every other month.
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Can you clarify:
Claim was out of network, went to BC? BCBS in many states do not have to honor AOB for non contracted providers.
Who was sent the full payment of the claim? Facility or patient?
I think that's why I'm confused.. not sure I understand who paid and who owes.
Game_Of_Billing:
--- Quote from: PMRNC on July 15, 2015, 04:03:13 PM ---
--- Quote ---HN's collection agency is attacking the facility directly which will hurt the business's credit rating.
--- End quote ---
Ok, but I was under the assumption from your original post that the patient was being pursued for collection? How does this affect the facility? I think I'm a bit confused because in another post you mention BC coming to you for reimbursement?
--- Quote ---About a month after filing the claim the insurance company paid out the full amount of our claim. Now 3 years later I get a call from a Collection agency demanding over 40k in reimbursement given HN does not pay a dime for our out of network facility. They claim we received 3 notices, first notice a month after payment and the other two every other month.
--- End quote ---
Can you clarify:
Claim was out of network, went to BC? BCBS in many states do not have to honor AOB for non contracted providers.
Who was sent the full payment of the claim? Facility or patient?
I think that's why I'm confused.. not sure I understand who paid and who owes.
--- End quote ---
Sorry, I am dealing with two claims;
1.in 2012 healthnet sent our out of network facility 40k payment directly to us and claims they sent 3 notices "that we never received" 2 months after sending the check due to paying out our facility as in network when we were out of network. The collection agency is pursuing our facility 3 years later... no calls were ever made to our facility. This is the first we heard of this.
2.blue cross is demanding payment directly from patient for 22k due to overpayment because of a plan price change. From what I have received so far it seems they paid in error at the prior years price .
** I am dealing with two difrent demands. One from health net demanding 40k payment directly from our facility for paying us as in network when we are out of network. Second is from Blue cross taking a patient to collections for an out of network check sent directly to the patient which was then forwarded to us.
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