retmar -> medical coll

[momof5]

I was reading your medical collections sticky above....

Could you provide some kind of legal support for this:

"7. If a claim is denied for some reason other than deductible not met, it is the sole responsibility of the provider to respond in kind for proper processing and payment. An example is if deneid as there may be another carrier who may be primary. The provider must obtain the info and resubmit claim with it. If they fail to do this in the within the time allowed, they must write off.

8. If a provider fails to file their claim within the time allowed by insurance carriers for filing, they must write off. Most times are one year from date of treatment."

I have one that I believe these apply to. I can't just simply say, "It's illegal, eat it...,etc...because retmar said so!"

Also....

I just had a new CA list a med debt. It is for Hosp. with a DOFD of 3/2006. Hosp is in FL in 3/2006 I was not. (I know this is an illegal reaging because it is listed in the DOFD....with "account opened" of 5/2006 and reported 9/2006" NO hospital turns an account over in 2 months.

I did look it up and there are NO EOBs in my insurance online stuff that would match the provider or the amount. Although I *know* DD was once treated at Hosp (ER), it was when she was a Freshman, she is now a junior....and so does the Hosp have to eat this because they didn't file the insurance?

Honestly, I think they did and this is the difference between what the insurance pd and what they billed.....

I don't have enough information to contact the insurance company because honestly, I don't have enough information. WAS this DD or one of my other kids? What year? (dunno)..... The CA is Accounts Receivable Management.

[dpgirl]

I'm not Retmar but I think I can help you at least a little. Be patient as Retmar has always reliably replied to questions in the past.

First of all you must have the EOB's from the insurance company in order to determine why a claim/amount was denied. If the reason is other than the deductible you need to determine if the amount not covered should be written off by the provider. This would depend on the type of insurance plan, PPO, HMO and whether or not the provider is a contracted provider with the insurance company. If so most likely the amount not covered is a write-off and the provider should write off that balance and not bill the patient. Now, providers make the mistake of not writing off these balances all the time and just billing the patient for any amount not covered by insurance. In my opinion this is what happens to providers who pay minimum wage to the office staff. It's a pain but you really have to keep on them.

You very well may be able to say "eat it" to the people contacting you for these balances but you need to be able to back it up with EOB information, three way call with the insurance company (I have done that)...that type of thing.

As far as the hospital in Florida, if you think it was your daughter perhaps she didn't give them the insurance information as you indicate it appears that the hospital never even billed the insurance company. I would call the hospital directly and get the information you need first hand. Find out if they ever obtained the insurance information and if so did they submit the claim. If so then you need to get a copy of the denial. Sometimes claims are paid but they are not applied to the correct patients account. They may even be after the wrong person entirely, who knows, but in this case contacting them may be a good idea.

Contact the insurance company anyway, they can look up any claims they recieved for the whole year of 2006 if necessary, I have done that too.

Also if for instance you have a ppo plan and the hospital is not contracted then they don't have a contractual obligation to bill the insurance company.

This is general information as I don't know what kind of insurance plan you have.

Maybe leave a few more details and more help will be forthcoming.

Good Luck.

[retmar]

Thanks dpgirl, for your input. Good info!

momof5, what you need to do first is what I said in the sticky and what dpgirl said here. Call your insurance first.

1. As to your DD's ER visit, have at least the date range of treatment available when you call. Also have the name of provider, such as ABC Emergency Physicians, and amount shown as balance due, even if it may contain added charges, fees, or interest. As to the date, you can use the date on your CR for reference, usually the earliest date showing. Why is because the DOLA on a medical claim could be up to 30 days past actual date of treatment due to the normal cycle of 30 days for billing turnaround. Or, if no insurance info was provide, it would be date of treatment. Also, on this item only. If it is found your DD did not give the insurance info, ask your insurance if they will still accept the claim even if past the alloted time. Many times they will accept this and pay accordingly.

2. As to others, use same info from your CR as shown for each claim. Give this to your insurance rep to find an EOB if you do not have one. Then, they can FAX it or mail it to you.

3. Ask the insurance rep to explain to you their R&R's involving assignement of a bill. Make note of this or ask them to send you the book for reference. Most carriers have a guide book for patients/beneficiaries and providers. Get all.

4. Once you have an EOB for each claimed account, note what is showing in the cost share, copay, or patients responsibility, whatever it is described as. If any or all show a zero balance, you are not liable for a penny of the claim, period.

5. If no EOB can be found, thus, no claim filed, you must have your insurance tell you of the paramenters of filing claims. An example is that if no claim filed within a year from date of treatment, they cannot bill you for the claim. If claimed filed, and denied, your insurance can tell you if you are or are not liable. Then, of course, you clarify if amount claimed is a billed amount or an allowed amount. If billed and provider is in the system, they are in violation of Federal Law for what is called Balance Billing. More on this if it applies.

Do realize that most insurance carriers only keep past records for a couple of years, but, do have access to their archives for further research. Sometimes you may have to wait for another person, such as a supervisor to get into the archives. As to how they attempt to locate a previous claim, our carrier aksed me for the date, then provider, but, was also able to bring up by provider, then search for a date. We also used the amount claimed to find one of ours that turned out to be a mutually excluded item. And, lastly, remember that most CA's report a debt at the next highest dollar if over $.50 or less if under. Worry about this only if needed as in your DD's since you have no other reference.

[LadynRed]

You also have to keep in mind that a lot of claim denials come from mis-coding, the wrong ICD-9 code is used for a procedure or service and only the PROVIDER can rectify that error. Coders are specialized, they must pass exams and be certified, but that doesn't mean the Fee ticket won't get mis-coded or have the wrong box checked on it !

[momof5]

Thanks everyone.....

I finally got a letter from the CA. It has what may be the real date of service (which if unpaid is also the DOFD).

It is past 1 year so I doubt if I can get it paid by the insurance co if they did not file and I will have to find out if this hospital is a provider (I believe they are). I HATE this ins company because it usually took threats of lawsuits to get them to pay for ANYTHING> and it is Blue Cross/Blue Shield!

Oh well, time for more of their crap so I can figure this out!

I know the last battle I had with them was about 6 months ago for my daughter A. I checked with them at that time on me and ALL 5 of my kids...that there were NO EOBs that showed a non-payment.

I guess this will take time and effort to resolve....

I will get back to ya when I get the real details.

[retmar]

LadynRed, amen to that. Thanks for pointing out.

momof5, good. Be firm and professional with your insurance. You know what to ask. If in doubt, go to the sticky and use the numbered items for reference. And, lastly, be sure and ask about the items LadynRed noted as this is something that happens more than people think.

Don't ask for anything else from the CA right now. Get your info from insurance in order so you know what you have to do.

[dpgirl]

If the hospital is a contracted provider and they did not bill within the timely filing limits, then this is a case where they do have to "eat it." Real simple.

If they did bill and it was denied for some reason then you have more work to do.

Keep us posted. I am rooting for you...Blue Cross is a tough one.

[momof5]

UPDATE:

OK, BCBS reloaded the EOB's on their system and I was able to pull them.

I am going to have to call them on Monday.... I have talked to the hospital.. This is what I found:

1. There are 2 different claims for Hospital. One is for "Emergency Services" the other is for "Radiology". The DOS was 12/16/2004. On the EOB's

a.) EACH had a $50 copay. Why? This was for one single treatment. (DD had hit her head hard on the soccer field and initially could not feel her feet so they had all sorts of radiology stuff done to find out why!)

b.) BOTH show co-insurance amounts. One for 6.67, the other for around $89. (I don't remember having any co-insurance!)

-> doesn't this mean that if there was co-insurance that the hospital was responsible for billing the other insurance company as well? If they failed to do this, does this mean I am not liable?

2. I chatted with a nice lady at the hospital. I told her that so much happened around that time and since they were billing that I never remembered seeing any bills from them and that I was willing to pay but I needed her to pull it back from the CA.

She said that they wouldn't do that. I told her that this is a shame because it is my personal policy never to pay a CA, but that I would pay the hospital directly. She then replied that if I did that, they would respond with telling the CA to have it marked a paid collection. I asked her to speak to a manager who might be willing to understand the situation and give a different decision. She said that she would have the manager call me on Monday.

I do have them on an FCRA violation. The DOFD is listed Mar 2006. As you can see, it was 12/2004!

This is the ONLY account that is keeping my score on EQ below 600! This does not appear on either of the other 2 bureaus and yet their scores are 655 and 659! EX only shows 1 med collection that is over 5 years old. TU has that med collection and 1 from progressive ($89) and one from a loan I got for my son that he didn't pay (yeah, I know) for $1900 which is 4 years old.

The other med collection tried to bill me for the whole thing ($1500). When I challenged that they changed the bill to $758. I tried to negotiate a PFD and was told no. I told the Dr. office manager that since it was past SOL, I wouldn't pay unless they deleted. This one is basically dead. Funny thing about this one....they updated (no change) on 3/17/2007 and that was the day it disappeared from EQ but is still on the other 2. I would hate to ask why from EQ only to get it reinserted.

What would be my next step?

eta: the CA is Accounts Receivables Management out of Miami. Does anyone have history with these folks? Will they PFD or 'fail to respond' to a dispute of a paid collection?

[retmar]

Regarding that $1500 that was dropped to $758. Was your insurance involved in that claim? If so, and the agreement between your insurance and the provider only allows you to be billed the allowable amount at most, say on a denied claim, you got this provider. This is called "Balance Billing" and is illegal under Federal Law, period. You will need to speak to your insurance to get the particulars. Make sure that if this is true in their agreement, ask them to send a letter to the provider advising of this.

Here is the tricky part of your other bills. XRay and Hospital are two different payees, in many cases. Look at the EOB's very close. You should see two different provider names. Then look to see what your responsibility, co pay, or cost share says. This is all you are liable for, period. The provider cannot bill you for any other amount. Remember, your insurance receives the whole billed amount, including all that transpired during the treatment. The insurance then breaks the billed amounts down to allowable amounts, then breaks it down as to amount paid, your responsibility, write offs by provider. Go back through the sticky to see what other things apply. Also, when you next talk to your insurance, have them go over the EOB's with you to assure you understand everything. Be sure and make notes on another piece of paper.

I'll check back in in a couple of days. Tomorrow is a very busy one for me.

[Methuss]

One more thing. If the hospital is in-network for your plan but a provider is not, call the hospital administrator and ask about it. As I found out, most hospitals require their subs to be in the same network as they are to avoid insurance snafus.

I recently had a problem with the pathology lab in the hospital billing me for bloodwork at full price because insurance said they were not in-network. It was true. The lab wasn't in network, but hte hospital was. The hospital administrator told me that the lab was contractually obliged to be in all the same networks as the hospital itself (and that it is standard practice for this to be done at all hospitals) and made them eat the cost.

[retmar]

Good Point, Methuss! Thanks for sharing!

[momof5]

Here is the latest update;

I didn't get the promised call on Monday so I googled the Patient Accounts Manager and found that name, email, ph # and that of the Hospital Administrator. I explained in the email about my questions and concerns and my willingness to pay if it would be deleted and gave my sob story about 2005 (the year from Hades).

Prior to the email, I did call the ins co. The problem was that they 'double billed' for the Medical Services. The first claim was only for Medical services. The second claim included the Medical Services and Radiology. BCBS admitted that there should have been only 1 co-pay and would immediately adjust the claim and remit the $50 to the hospital. I asked about the co-insurance. My bad. I thought that this meant there was more than one insurance company. This was my portion to pay the hospital.

So, my balance would then be $146. I received a near immediate reply from the Patient Accounts Manager asking if she could help. I called and left a message. She called me the first thing the next morning. She stated that she would accept the $146 and wait on the $50 and that she would notify the CA and I could expect deletion within 30 days. I memorialized the conversation in a reply email to her. She said that I should be receiving a 'confirmation' email from her (has not sent it yet) and that I should also get a confirmation letter from the CA.

I wanted to appear genuinely cooperative with her and I realized at the end of the conversation that I didn't get the PFD in writing. (Yes, my bad - but I hope that she will accomplish this.) Secondly, the DOFD is off by 2 years (and I pointed that out to her) so I will have a dispute if it comes back as a paid collection instead of a deletion. I will then use the Hosp Admin's email and hers to challenge the failure to delete, inaccurate DOFD or whatever.

Time will tell.

[retmar]

To assure you properly saved the emails, I would print out each of them as well as save them to documents. You did right by responding to the phone call with an email that included points of the conversation. Why I say this is if she does not respond as to "I didn't say that", how can she come forward later and deny it?

In regards to the claim you would receive leters from her and the CA, I would wait maybe two more weeks, then, if no letter, send her another email reminding her of the original agreement between you two.