CASE STUDY: COORDINATION OF BENEFITS PROBLEMS

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Situation

A 36 year old woman required extensive services from her obstetrician during her high-risk pregnancy. These services involved a number of ultrasounds throughout her pregnancy to monitor the growth of the fetus. After a healthy baby was born, the woman began receiving bills from her physician for services that previously had been billed to her insurance company and paid by them. She didn’t understand why she was being billed for services that had been paid already. Through her investigation, she learned that her insurer had requested refunds of the payments made to her physician for services provided during the last three months of her pregnancy stating that the policy was not in effect for those dates of service. For 5 months, the woman attempted to correct the issue of coverage and payment, and was unsuccessful. She was being billed by her physician for more than $2,000 in charges, and was receiving harassing phone calls and emails regarding collection.

THE PATIENT CALLED SYSTEMEDIC

Through a series of conversations with the insurer and the provider, we learned that a few problems had occurred to create this billing issue. The first was a coordination of benefits issue: her insurer erroneously determined that her coverage with them ended because they believed she had other coverage at the time. This determination triggered a series of letters to her provider requesting refunds for the payments made for the dates of service in question. Once we clarified with her insurer that she had no other coverage at the time and that premiums were paid, the insurer confirmed that the coverage was in fact in effect for these dates of service. We requested that they cancel their request for refund and inform the practice that they were no longer requesting the return of those funds. The refund retraction letter was mailed to the practice.

Allowing time for the retraction letter to be received by the practice, we next contacted the provider to confirm that they were aware that the insurer had made an error and that they were no longer requesting the refunds. They confirmed that the issue with this patient’s coordination of benefits had been resolved once they received the retraction letter from the insurer. We requested that they correct their bills to the patient to show that the funds were not being retracted and send the patient a bill indicating that she had a zero balance for these dates of service.

The provider refused. They said they had no way of sending the patient a zero balance bill and that the patient would just have to take their word that there was no balance due. We indicated that the patient had a bill showing a balance of $2,250 To ensure that she had no financial liability for these charges, she wanted written confirmation. Again they refused.

The next set of calls was with the insurer to inform them of the actions of this network provider. They reached out to their Recovery Department to secure a copy of the refund retraction letter that was resent to the practice. Additionally, they contacted the practice to confirm the retraction and to indicate their displeasure with the treatment of their member. The retraction letter was forwarded to the patient along with copies of all explanations of benefits that showed that the claims had been paid in full by the insurer, and that the patient was only responsible for copays that she might not have paid already.

BOTTOM LINE: The patient was responsible to pay one copay that had not been paid. The full balance charged to the patient was removed, saving the patient $2,250.

EMERGENCY DELIVERY CAN HAVE ITS COSTS

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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.

 

STUDY MEDICAL BILLS CAREFULLY…80% HAVE ERRORS

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SITUATION

A 25 year-old female with persistent nasal congestion, sinus pressure, and sore throat that had not responded to numerous treatments prescribed by her primary care doctor

PATIENT PROCESS

In a phone call to her doctor, the patient was instructed to return to the office that day to see an ENT (Ears/Nose/Throat) Specialist in the same medical practice.

During this visit, the ENT examined the patient and performed a procedure that involved placing a scope in her nose to view the nasal and sinus passages.  She was given two prescriptions to treat the condition.  The patient paid her copay and left.

Approximately 3 weeks after the visit, the patient received a bill for $205.66 from the ENT.  Three to four weeks later, she received another bill for $441.96 from the same doctor.  When she called the office for an explanation, she was told that this visit processed to her in network deductible.  No one explained the price disparity.  She spoke to her insurance company and they stated the claim was processed correctly and the charges were applied to her deductible.  The $441.96 charge was correct.

The patient called Systemedic.

We reviewed all explanations of benefits and bills from the doctor and noted that the claim had been submitted more than one time to the patient’s insurance.  In order to investigate the billing process, we then requested office notes to compare to the charged procedures.

We uncovered the following discrepancies:

  •  The visit was billed as an emergency room visit, a code that can only be billed in a hospital.  This code pays at a higher rate than a standard office visit.
  • Both claims for the visit were billed incorrectly.  In each case, an additional procedure was billed even though it had not been performed.

Conversations with the billing manager at the practice pointed out these discrepancies and the severity of these billing errors… how services were coded at higher levels than the notes supported, and how procedures that were not conducted were billed.  The patient did have a deductible to fulfill but because of our billing and coding knowledge, the patient’s overall financial responsibility was reduced in two ways: to reflect only the fees for the proper coding of the visit and to reflect an additional negotiated cost reduction for the time and effort that was invested to resolve this billing error.

BOTTOM LINE: THE PATIENT SAVED:

–          MORE THAN $300

–          COUNTLESS STRESSFUL HOURS ON THE PHONE WITH THE DOCTOR’S OFFICE

–          COUNTLESS STRESSFUL HOURS ON THE PHONE WITH THE INSURANCE COMPANY

–          THE GROWING RISK THAT HER ACCOUNT WOULD BE SENT TO COLLECTION FOR NONPAYMENT

BE SURE TO WAIT FOR AUTHORIZATIONS

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Situation

A 23 year old woman suffered from a variety of symptoms, including extreme fatigue, dizziness, and joint pain, symptoms that increased in type and frequency and grew to include headaches, memory loss, difficulties concentrating, hair loss, facial and extremity numbness, blurry vision, and chest pain over the course of 2 years.  Attempting to find a cause and treatment for her symptoms, the patient consulted a number of physicians from internists to rheumatologists and infectious disease specialists.  A multitude of blood tests were conducted with no diagnosis.  She was treated for Lyme Disease twice, but the symptoms continued.  An exacerbation of her symptoms that suggested that she might have experienced a stroke, sent her to the emergency room.  She still had no answer.

On the recommendation of a family member, the patient scheduled an appointment with a well-known and highly regarded internist in the community.  He determined that she should undergo an MRI of the brain.

This procedure needed to be authorized in order for her insurance to pay for the procedure.  The doctor submitted a request for the authorization, but it was denied.  Before the office was able to appeal the denial, the patient scheduled the MRI at the local hospital.  When she arrived there, she was told that the procedure was not authorized.  The only way the hospital would move ahead with the MRI was if the patient paid in full for the procedure.  Being frozen by fear for her health and overwhelmed by the nearly 2 year process leading up to this point and desperate for an answer, the patient paid $3,053 and proceeded to have the MRI.

 THE PATIENT CALLED SYSTEMEDIC FOR HELP

In the process of our collecting medical records and developing an appeal to be submitted to the patient’s insurance company, we contacted the hospital that provided the procedure to secure a copy of their bill for the appeal.  At that time, we learned that the hospital had violated proper billing procedures.  As an in-network facility, the hospital was required to submit a claim for the MRI to the patient’s insurer, even though that procedure was paid in full by the patient at the time of the visit.  Instead, they did nothing.  We insisted that they submit the claim to the insurer as they were required by their contract with the insurer.  After many refusals to do so, they eventually succumbed to our pressure and submitted the claim to the insurer.

Resolution

By the time the claim reached the insurance company, the authorization, originally denied, was overturned as a result of the prescribing physician’s appeal.  This enabled the claim to be paid in full by the insurance company at the in network rate of $1,212.91, not the out of network rate of $3,053.  The patient had no financial responsibility for the procedure.

We recontacted the hospital to confirm their receipt of payment by the insurer and requested a full refund of $3,053 to the patient.

 

BOTTOM LINE:  THE PATIENT SAVED $3,053

ARE ALL YEARLY WELL VISITS TRULY FREE?

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Situation

 

A 30 year-old male wanted to schedule a yearly physical/well visit with his primary care doctor.  He assumed that this visit and all procedures associated with it should be fully covered and paid by his insurance company without any out-of-pocket cost to him.  His doctor was in-network.

 Patient Called Systemedic for Advice

 Systemedic informed the patient that while the new healthcare laws provide for one physical/well visit each year without cost to the patient, the law is not so straight forward.  The actual coverage relies on the definition of “well visit” by both the doctor and the insurance company.

The United States Preventive Services Task Force, an independent panel of national experts in prevention and evidence-based medicine, provides recommendations on preventive services including screenings, counseling, and medications that help to improve the health of all Americans.  Generally, insurance companies use these guidelines to determine which services they will include in their yearly physical/well visit coverage.

HOWEVER, every doctor independently determines which services, procedures, and tests to include in his/her standard yearly physical/well visit.  There is NO guarantee that any or all of these services, procedures, and tests are either recommended by the US Task Force or covered 100% by a patient’s insurance company without patient financial responsibility.

Systemedic Actions

We recommended that prior to scheduling the appointment, the patient call his doctor’s office and ask for all the procedure codes and diagnoses codes that would be used for billing his physical/well visit.  Systemedic then contacted his insurance company to confirm how each of these services and procedures would be processed and paid.  Systemedic discovered that three procedures, while covered by his policy, were not covered as part of the free yearly physical/well visit.  Those procedures would be applied to his deductible.  Since he had not satisfied his deductible yet, if he received those three services, his financial responsibility for them would be $832.53.

Systemedic suggested that the patient contact his doctor’s office in advance to discuss what we learned about the limitations of his policy coverage.  The patient indicated that he was not able to afford to pay for these tests.  The doctor agreed that he would conduct the yearly physical/well visit without those tests as long as the patient signed a waiver.  Additionally, the doctor indicated that should any of the results from the other covered tests suggest the need for any or all of the three tests that the patient initially rejected, the doctor would strongly recommend that those tests be performed.

 BOTTOM LINE:

  • THE PATIENT SAVED $832.53

  • NO FURTHER TESTING WAS NECESSARY