Medical Billing Question

icuRNmaggie, BSN, RN · Jun 25, 2015

Contact your state insurance commission for assistance.

Years ago I obtained preauthorization in writing from the PPO for surgery as required. I had full names and phone numbers for the people who authorized the surgery. Payment was denied.

I called BCBS and stated that I would report this to the State insurance commision as well as anyone else that I could think of who regulates their industry.

The surgeon received payment that very week and his office staff wanted to know "how did you do that?"

icuRNmaggie, BSN, RN · Jun 26, 2015

My friend is retired from the military and works in management for my home state's insurance commission. His mission in life is to protect the consumer and hold insurers accountable for bad practices. The fines can be substantial. Whether it is non payment or a failure to mitigate the damages in a homeowner's claim, these

state employees work for the policy holder. Having my friend's business card or mentioning the insurance commission is enough to get the insurer to settle the claim as stated in the policy.

Jolie, BSN · Jun 26, 2015

Thanks so much for your input. Uncharacteristically, it is not the insurance company that I blame for this situation.

I received very intensive services from a multi-specialty group in early 2014. My care involved a number of practitioners from different disciplines that were all employed by the same practice. I went there because the doctor coordinating my care had moved his practice there, and I trusted him implicitly (and still do since he has had the good sense to leave the practice and go elsewhere.)

I realized that January 2014 was the advent of Obamacare and this was a relatively new practice with a small billing office. I anticipated that the early part of the year would be challenging for the business office as they began to work with new insurance plans and many patients' plans that changed as of the first of the year.

By early April I had not received a single EOB from my insurer, despite having about 12 visits to the office. I asked about it when I was there for an appointment and was assured that they had been back-logged, but were getting thru the billing and I should begin to see them soon. By June, after approximately 20 visits, I received my first EOB, and it was for a recent visit, not one from early in the year. I asked again, and was told that that EOB was a sign that things "were beginning to move thru the system."

In August, I called the business office and left a message asking for a return call from the billing manager which never came. Same thing in October. Not only had I received a minimal number of EOBs, I had never been billed for any deductible or co-insurance amount. Since we have a high-deductible plan, and since I had received so many services, I knew my bill had to be substantial and I wanted to begin paying it, rather than get hit with the national debt at the end of the year. I finally received a statement from the practice in November which listed every visit since January, along with notations that each visit had been submitted to insurance, the amount of discount and a running balance.

At the time I received the bill, all hell was breaking loose, with my health, at work, and with a family situation. Normally, I would have gone over the bill carefully before paying, but given the circumstances, I just paid it, thinking I would check it later.

Later finally came when we did our taxes in April. In totaling our health expenses for the purposes of taking a tax deduction, we realized that we had significantly overpaid our deductible and OOP maximum. My first instinct was to blame the insurance company, assuming they pulled a fast one and failed to credit us for something we had paid. I spent the better part of a day with a very patient representative from Big Insurer who reviewed every single expense for every family member. It wasn't until we got to my visits that we found the problem The practice never submitted the first 15 or so visits I had in the early part of the year. That amounted to nearly $2000 that I paid on their bill that was never reported to Big Insurer. To summarize, the statement that they sent me and I paid in November amounted to a creatively written piece of fiction. The notations of submission to the insurance company were falsified, apparently by someone who was VERY behind in his/her work, and (wrongly) assumed that because our deductible was so high, we would never meet it anyway.

Upon figuring this out, I contacted the practice in April and had a conversation with a newly appointed business office manager. She was to speak to the higher ups in the practice and get back to me. Never did. I called again this month and made enough of a pest of myself that I finally was transferred to the latest and greatest office manager, who is now submitting these claims to Big Insurer. They are all now over a year old, and I have serious doubts that they will be allowed. That is the basis for my original question.

My stance is that if Big Insurer pays on these claims, the practice needs to immediately issue me a full refund for those that I paid last year, and if Big Insurer refuses to pay, then I am due a credit in the amount that I overpaid my deductible and OOP max, which is about $2K. Coincidentally, that is about what I owe for this year's services that I have refused to pay until this mess is settled.

On the bright side, my doctor realized what a mess this practice was and has moved. I couldn't be happier about that. Now to get my checkbook back in order....