Payments > Insurance Payments
retro denial question
djaeger:
Hi everyone. I am new to this board and new to billing. We called for approval for pt to have thyroidectomy. Approval given, doc performed surgery, claim paid. Later.....told that ins co wants their money back because the patient's employer had quit paying the premiums on the policy, and in fact, patient was NOT covered during the time of the surgery. (Ins. canceled 7/1/09, we called to verify 7/16, surgery performed 7/21). Do we have any recourse at all in this case? Doesn't seem fair that doc has to suck this up. How can you protect yourself in the future from this happening? Any ideas?
Thanks in advance!!!!
Pay_My_Claims:
well its one of those things that happens, they tell you "authorizations isn't a guarantee of payment" If the client isn't covered.....he has to pay
Michele:
I'm afraid Charlene's right. Prior approval is not a guarantee of benefits. But in this case, the patient should go after their employer. Bottom line it is the patient's problem. The dr doesn't need to eat it, the patient has to pay.
Michele
PMRNC:
I concur, if a plan's premium is not paid, they are given a grace period. When underwriting cancels, claims paid in error are automatically "rescinded" because technically the patient did not have coverage.
oneround:
Correct me if I'm wrong ladies but in CA. our providers are protected by AB1324. If a Health plan Auth it, they pay it, as long as the provider determined eligibilty and provided services in good faith upon that Auth. The payer. at least here, cannot go after the MD but can go after the policy holder, who in turn should go after their employer. I have heard that other states have adopted that bill also. May want to check your state AB's. Does not hurt to try, you may have one or you may not. I can say that when I was in claims when we encountered similar scenarios we had to foot the bill up until the auth date ended. I can check with my legal department on this particular case. Becausue I remember many mettings with the payors, our UM department and legal on this. Here is a little blip f that bill
SUBJECT : Health care coverage: rescinded coverage.
SUMMARY : Clarifies and makes specific provisions of law that
currently prohibit health care service plans (health plans) and
disability insurers selling health insurance (health insurers),
where the plan or insurer authorizes a specific type of
treatment by a health care provider, from rescinding or
modifying the authorization after the provider renders the
health care service in good faith and pursuant to the
authorization. Specifically, this bill :
1)Clarifies that a provider has rendered health care services in
good faith when the plan or insurer has authorized services by
verifying eligibility of a member or policyholder, or
otherwise communicating that the member is covered under the
plan contract or insurance policy, or, in the case where the
member's plan contract or policy requires preapproval, the
provider has obtained the preapproval.
2)Clarifies that a health plan or insurer does not avoid its
obligations related to the existing prohibition against
rescinding or modifying an authorization for treatment by
rescinding or modifying the contract of the enrollee or
insured.
3)Finds and declares that the changes in this bill do not
constitute a change in, but are declaratory of existing law.
EXISTING LAW :
1)Provides for regulation of health care service plans by the
Department of Managed Health Care (DMHC) under the Knox-Keene
Health Care Service Plan Act of 1975 (Knox-Keene) and for
regulation of disability insurers who sell health insurance
(health insurers) by the California Department of Insurance
(CDI) under the Insurance Code.
2)Prohibits health plans and health insurers, where the plan or
insurer authorizes a specific type of treatment by a health
AB 1324
Page 2
care provider, from rescinding or modifying the authorization
after the provider renders the health care service in good
faith and pursuant to the authorization.
3)Prohibits health plans and insurers from engaging in
"post-claims underwriting" defined as rescinding, canceling,
or limiting of a plan contract due to a plan or insurer's
failure to complete medical underwriting and resolve all
reasonable questions arising from written information
submitted on or with an application before issuing the plan
contract or policy. For health plans regulated by DMHC,
provides that the prohibition against post-claims underwriting
does not limit a plan's remedies upon a showing of willful
misrepresentation.
4)Requires applications for health plan contracts or health
insurance policies to conform to certain standards for
underwriting, including clear and unambiguous questions when
health-related questions are used to ascertain an applicant's
health.
FISCAL EFFECT : None
COMMENTS :
1)PURPOSE OF THIS BILL . According to the author, this bill is
necessary because even though existing law explicitly
prohibits plans and insurers from refusing to pay providers in
the event of retroactive rescission of coverage, health plans
and insurers aggressively continue to skirt the legislative
intent. The author argues that this bill will reaffirm that
authorization includes verification of eligibility, thereby
ensuring that once a treatment is authorized plans and
insurers will have no incentive to save money by canceling or
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