Consequences of not following through

[deltadawn]

It appears that Jun 2005 was not a very good month - that was the month all my credit problems occurred - all medical and 1 30 day late payment.

I've mentioned my situation in a previous post; however, I want to repair my credit and want to deal with one issue at a time.

Received a copy of medical services provided that was sent to insurance company for payment (not an actual bill). Insurance denied claim on the basis that services were not covered. I requested that the Medical Provider resubmit claim (over phone - no records) because spouse had the same services performed and the Insurance Provider paid the claim (same insurance policy). I never received any paperwork stating it was resubmitted.

In Nov 2005, this was placed on credit reports as a collection. There have been no collection calls and the only written correspondence I have is in Dec 2005. (This was a letter that was stuck in my personal records, which, had been unopened until recently - I honestly believed that this had been resolved; however, I realize it was my responcibility to follow through and now face the consequences.

After reading various posts - I decided to procede with why chat's Hipaa procedure. I had a feeling of enpowerment and felt that the best way to predict my financial future was to have a plan of action and follow through.

I opted out and have sent letters to CRA's to delete old addresses.

I know that this has worked for some of you in this forum. It sounded good and I was ancious to have a "quick fix" to my credit repair.

However, I no longer feel confident that this is the correct process for me. First of all, there has been no Hipaa violation. I have also concluded that there has been no FCRA violation (if I am interpreting what I have read correctly).

Therefore, I have decided I have 2 choices: either "put my head in the sand" and hope that I don't get sued or meet this "head on" and call them.

The "right thing" choice is to call them and pay my bill; however, I'm extremely nervous and hesitant about calling. Best case scenerio, from what I have read, is asking for a PFD. Any suggestions on how to approach this without sounding like "if you don't do it, I won't pay"? Should I let them know that the same services were performed 5 days earlier and the Insurance Provider did pay?

The company that has placed this on my credit report is the collections department within the billing services for the Medical Provider.

[Robert Nashville/Savannah]

The people you need to be talking to are at your insuracne company; they have appeal processes.

I'd at least want them to explain why they would cover services for you husband but not for you when it's the same policy (you might even have a claim of sex descriminatino unless they have a very good excuse).

If that doesn't resolve the problem and you have the money to pay/settle then I'd asvice you to do so with or without a PFD (but I'd try and get a PFD if at all possible).

[cjtx]

I agree with Robert that you should appeal your claim with the insurance company.

At the same time, send a goodwill letter to your doctor, explain the situation and offer to pay what you owe (PFD).

The whychat method, as I understand it, helps you get rid of medical collections on your credit report, but only those you already paid off. Once the debt is paid off, reporting the debt becomes a HIPAA violation, because there is no more debt to collect and the exception under which a CA can report medical accounts for collection purposes is gone.

[deltadawn]

I am no longer with the Insurance Provider. However, I can contact them tomorrow. I did go to their web site and read that any disputes would have to be within one year of the service provided (which I did not do - I only asked the Medical Provider to resubmit)

Evidently this is a large corporation that has a lot of diverse divisions.

The logo on all my paperwork is the same - insurance, doctor, and collections (actually, they refer to it as accounts receivable - fancy name for collections).

The Insurance Provider and Collections all have the same street address - just a different PO Box to distinquish which department it goes to.

Since this has been over 3 years ago, if I contact the Insurance Provider and fax them the copy of my explanation of benefits along with my spouses, can they now try and collect on the services they paid (if indeed it was not suppose to be covered by the policy)? Will I be opening a can of worms?

[Robert Nashville/Savannah]

If they are already trying to collect then I don't know what the can of worms would be.

Whether you are still with the insurance provider is unimportant; however, if you didn't follow their procedure during the proscribed time then you may well be too late to accomplish anything.

[deltadawn]

If they are already trying to collect then I don't know what the can of worms would be.

Keep in mind I have not had any communication with them since 2005.

Whether you are still with the insurance provider is unimportant; however, if you didn't follow their procedure during the proscribed time then you may well be too late to accomplish anything.

Thus the title to my thread - I have accepted the fact that since I did not follow through, I must accept the consequences. I just wondered if their inconsistancy would give me any leverage when asking for PFD.

I am trying very hard to think rationally; however, emotionally, I am a wreck.

This forum has been a tremendous support for me. I felt very confident with my initial plan of action; however, the more I read (HIPPA, FCRA, FCBA, FDCPA, UT Statutes, etc.) the more vulnerable I felt. It became apparent that going that route was a "scape goat" and not completely ethical.

So trying a new approach for my irresponsibility.

[deltadawn]

The whychat method, as I understand it, helps you get rid of medical collections on your credit report, but only those you already paid off. Once the debt is paid off, reporting the debt becomes a HIPAA violation, because there is no more debt to collect and the exception under which a CA can report medical accounts for collection purposes is gone

I also have 2 paid medicals showing up on my CR - all in Jun 05 - that I wanted deleted.

why chat told me to:

1. Opt Out

2. Delete Old Addresses

3. Send PreHipaa Dispute Letter to CRA's (which states you have no

knowledge of the account and to provide you with an accounting -

which is not their responsibility)

4. Then send payment (which I would have to contact someone for

the balance) along with a HIPAA letter to creditor owed and just the

Hipaa Letter to paid accounts.

I think the basic theory behind this is to have the CRA's investigate the account, thus it would be treated as a disputed account. the CA has been paid there is no reason for them to verify.

I would much rather go this route. I'm open to any suggestions and willing to put this back on the table.

[deltadawn]

It would be greatly appreciated if someone could decipher this Ut Statute.

I have tried to make sense of it; however, it seems I translate it differently each time I read it.

Hoping that someone else can interpret it objectively.

Thanks

26-19-8. Statute of limitations -- Survival of right of action -- Insurance policy not to limit time allowed for recovery.

(1) (a) Subject to Subsection (6), action commenced by the department under this chapter against a health insurance entity must be commenced within:

(i) subject to Subsection (7), six years after the day on which the department submits the claim for recovery or payment for the health care item or service upon which the action is based; or

(ii) six months after the date of the last payment for medical assistance, whichever is later.

( An action against any other third party, the recipient, or anyone to whom the proceeds are payable must be commenced within:

(i) four years after the date of the injury or onset of the illness; or

(ii) six months after the date of the last payment for medical assistance, whichever is later.

(2) The death of the recipient does not abate any right of action established by this chapter.

(3) (a) No insurance policy issued or renewed after June 1, 1981, may contain any provision that limits the time in which the department may submit its claim to recover medical assistance benefits to a period of less than 24 months from the date the provider furnishes services or goods to the recipient.

( No insurance policy issued or renewed after April 30, 2007, may contain any provision that limits the time in which the department may submit its claim to recover medical assistance benefits to a period of less than that described in Subsection (1)(a).

(4) The provisions of this section do not apply to Section 26-19-13.5.

(5) The provisions of this section supercede any other sections regarding the time limit in which an action must be commenced, including Section 75-7-509.

(6) (a) Subsection (1)(a) extends the statute of limitations on a cause of action described in Subsection (1)(a) that was not time-barred on or before April 30, 2007.

( Subsection (1)(a) does not revive a cause of action that was time-barred on or before April 30, 2007.

(7) An action described in Subsection (1)(a) may not be commenced if the claim for recovery or payment described in Subsection (1)(a)(i) is submitted later than three years after the day on which the health care item or service upon which the claim is based was provided.

[deltadawn]

bump

[deltadawn]

I contacted the Insurance Provider and they told me that the claim was not paid due to the way it was billed (general examination to adminstrative purposes rather than regular medical exam).

They have no record of the Medical Provider rebilling.

Since it has been over a year, the only thing I can do is appeal. The Insurance Provider will be sending me the paperwork for that process.

Should I contact the collection department (even though I have not heard from them since 2005) to advise them that I will be appealing this or should I just go through the process for the outcome before notifying them?

Should I write a letter to the CRA's to notify them?

I have no idea what happens during a medical appeals process. Does anyone else know?

[Robert Nashville/Savannah]

The CA won't care that you are appealing to the insurance company (especially since they aren't even actively communicating with you) and the CRA especially doesn't care.

So...no reason to "inform" either of them of anything at this point.

[deltadawn]

Thank you Robert -

I guess at this point, I'm the only one concerned (DH believes that I'm being obsessive and anul over this); so I will just procede with the appeal and see where that leads me.

[deltadawn]

I received the appeal and complaint form today - not exactly what I was expecting.

4 questions to be answered and a signature releasing authorization for them to investigate and review medical and financial records relating to my health. They are not even asking that it be notarized.

1. Explanation of complaint

2. What written and/or oral communication have you received? From whom?

3. Extenuating circumstances or additional information

4. What is your expectation for resolution?

I guess my complaint is should not be with the Insurance Provider but with the Medical Provider, since they did not follow through and rebill.

This is all one company - just different divisions. I can't understand the lack of communication.

Insurance Provider - IHC Select Health

Medical Provider - IHC Physician Group

Collections - IHC Accounts Receivable

What type of extenuating circumstances would justify not following through?

I thought I had followed through by asking the Medical Provider to rebill. My medical file for 2005 is 3 inches thick. That year I went through tests for thyroid cancer, a heart procedure, therapy for a fall I had a work and DH's kidneys were funtioning at 30%. These are not extenuating circumstances - they only are excuses showing that I was overwhelmed with all the paper work I was receiving from doctors, insurance, hospital, etc.

What type of resolution does an Insurance Provider normally consider?

Now that I have vented and since I know that it is my bill (through verifications of my records) should I fill out the insurance appeal/complaint form? Should I contact the OC to advise them that the Insurance Provider does not show that they rebilled and ask for a copy of their request? Should I just try the PFD route? Or should I do all three?

[Robert Nashville/Savannah]

Perhaps your "justification" is that you shouldn't be held financially responsible for charges and/or that coverage shouldn't be denied simply because their "in house/captive" providers didn't submit the bills properly.

[deltadawn]

Robert - Thank you again. Excellent advice. Although I'm not expecting much from the Insurance Provider, at least I will know that I tried. The amount of the services is not devastating and I need to put this in perspective - it's around $250 (and I'm sure the collection department will have interest and penalties attatched).

If nothing else, I've learned an invaluable lesson.

[deltadawn]

Received form letter today stating that my review will be going into Step 1 of the formal appeal process.

Letter states that all pertinent info will be reviewed by the Appeals dept, Customer Complaint Review Committe or a healt care professional who has training in the same field of medicine as the treating provider. The appeal will be reviewed by at least 1 person who was not involved in the initial determination.

Should I want someone else to represent you, an Authorization to Disclose Health form must be signed & submitted.

I'm sure that this is a formality - but with Robert's suggestion, I did not receive a NO. The letter did indicate that this takes approximately 30 days to complete the review.

Does anyone know how this process actually works? It appears that if this is Step 1, there must be other steps in this process. (Basically I was expecting either denied due to ..... or granted.)

[swirlgirl]

Check your insurance company's website. Most explain the appeal process.

[deltadawn]

Update - Just received notification from the Insurance Appeals Specialist and am happy with the results. The letter reads as follows:

An appeals specialist who has experience in benefits interpretation and adjudication has reviewed your request for coverage of the services you received.

After careful evaluation of yur request, your medical records and the guidelines of the Plan, it has been determined that your request will be granted. The claim will be reprocessed and applied to the plan's benefits. You will remain reponsible for all applicable deductible, coinsurance and copay amounts.

We are happy to assit you in the matter. If you have further benefit questions, please call xxxxxxxxx and a representative will assist you.

I want to thank everyone for their assistance in resolving this matter - I did not even know how to begn to dispute this issue. I would have never been able to accomplish this without your guidence.

My copay was paid at time of service - so I assume I will have 3+ years of late charges to deal with. I requested that this be deleted from CRA's; however, that request was never mentioned - so I assume that I will need to start disputing once I receive notification that the bill was paid since the letter states that it is being reprocessed.

It's a bitter-sweet decission - I have had no luck in disputing with the CRA's.

Robert_Nashville - a special thanks to you!

[deltadawn]

The claim will be reprocessed and applied to the plan's benefits.

Just a clarification - Will this be applied to the plan's benefits plan for the year that it occured or this years plan? The reason I ask is because I have not met my deductable for this year.

My understanding is that this is being done automatically and I do not have to contact the medical provider to resubmit. Does anyone read this differently?

[isislc]

Sorry for jumping in so late on this but most likely it will be the year the even took place. If you are due a refund for that previous year after the deductible has been recalculated with this change, then they should mail you a check as a refund for that year depending on what was outstanding.

[deltadawn]

Sorry for jumping in so late on this but most likely it will be the year the even took place. If you are due a refund for that previous year after the deductible has been recalculated with this change, then they should mail you a check as a refund for that year depending on what was outstanding.

Thanks for responding - This all occured in 2005 in which I had a lot of medical expenses. I did not pay the bill and did not even know it existed until I pulled up my credit reports - so no refund would be due.

This is the second year that I pulled up my credit reports....The first year, I pulled them up - but did not understand the importance of following through.

Thanks to this board, I'm learning.

[isislc]

NP, you gotta start somewhere and unfortunately, most lessons have been painful and brought us here as a result.

[deltadawn]

..........and the saga continues

I decided to ctc the Insurance Provider this afternoon to verify if I needed to contact the Medical Provider to resubmit the claim or if they did it automatically. I was advised that everything should have been forwarded to my former employer, which was self-insured. Since the benefits are no longer administered through them, they no longer have access to the company's checking account.

WTH....They have no telephone number for me to call; however, did provide me with an email address. Since my former company is back east, it's too late to ctc them today...........so, I guess I know what my agenda is for Monday.

[deltadawn]

Well....it looks as though this is not getting resolved. Former employer HR directs me to former Ins Prov and former Ins Prov directs me to former employer. Former employer based in Atlanta, Ga. They do operate out of Utah. I know I can write a complaint to BBB and AG (which state or both?). I assume I need to write letters to NAIC and the state insurance regulator. My former company was self-insured. Does that make a difference to whom I complain?

[deltadawn]

Sent an email to former employer re. this issue. Finally received a response.

Deltadawn, xxx Benefits Accounting department contacted Health Services regarding your request below. Since it has been determined that payment to the provider is appropriate, they will submit payment on Thursday to Medical Provider/Dr. zzz for DH claim expenses in the amount of $181.35 for services provided on 3/14/2005. This amount is the contracted approved rate at the time of that service. Dr. zzz's office will be contacted this week to advise them to expect payment.

I'm sorry it took so long to respond to you, but since this claim was several years old and xxx no longer contracts with IHC, it took some time to get this resolved. I trust, however, that this answers your concerns as this claims issue should now be resolved.

Best regards,

Hopefully, this will be resolved within the next week. The actual medical bill shows 237.00 - the 181.35 is a contracted amount (which the dr office normally adjusts the bill - don't know if that will happen over 3 years later).

It appears that the payment will be made directly to doctor's office. How do I proceed since this has been turned over to a collection agency (also IHC)?

The email I received did not address that I wanted this deleted from DH's credit report. Since I have not been successful in deleting anything with CRA's, I want to make sure that I do this properly. Is the 1-2 punch appropriate action for this situation?

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