SITUATION

A 32 year old woman was pregnant.  She had insurance coverage through her husband’s employer.  She received all of her prenatal care through in-network doctors and facilities.  All of the prenatal claims were submitted to her husband’s insurance and paid by them.

She was scheduled to deliver at an in-network hospital when she encountered an issue that required that she deliver immediately, 4 weeks before her planned delivery date.  Because her planned delivery hospital was not close enough to accommodate the urgency of her emergent situation, she went to a hospital that was closer to her where she delivered her son.  The facility submitted their bills to her insurance and they were paid.

Five months after the birth of her son, the patient received correspondence from her primary insurance that they were requesting refunds from the hospital and all providers that they had paid.  They determined that they were not primary for her or her son’s care.  The patient was now responsible for over $42,000 in medical bills, bills that reflected that the patient was self-pay and not eligible for in-network rates since she had no insurance coverage.

THE PATIENT CALLED SYSTEMEDIC

As we conducted our forensic review of the situation, we uncovered that the patient had purchased, on the state Exchange, another insurance policy for herself.  She had neglected to tell any of her providers that this policy existed.  Because of this, every provider and facility billed her husband’s policy, which was actually secondary to her own Exchange policy.

In a normal situation, the providers would simply rebill their charges to the patient’s primary insurance, in this instance, her Exchange policy, and they would then cover the charges.  However, the Exchange policy required that the services be authorized in advance of the care.  The authorization could not be backdated, and therefore, they would make no payment.

We turned our focus to her husband’s policy to negotiate a payment as her secondary carrier.  While these payments were not as much as what they had paid as primary, they did reduce her overall responsibility for the prenatal and delivery costs.  Additionally, because the hospital had determined that the patient had no coverage, the $42,000 was a self-pay rate, a rate significantly higher than an in-network rate.  We were able to convince them that she should only be charged in-network rates because she, in fact, was covered by insurance, even though the authorization did not exist.  This acceptance further reduced the patient’s financial responsibility to the hospital.

BOTTOM LINE: IN TOTAL, THE PATIENT PAID $6,000 TO THE HOSPITAL, FOR A TOTAL SAVINGS OF $36,000.


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