In September I raised the issue of whether the primary responsibility of Union Health Plan Commissioners is the protection of the Plan or the Union members? With LineCo (the Union), the Plan requires completion of a course of treatment in order for any benefits to be paid out.
The case involved a member who had completed inpatient treatment near the end of one month and was scheduled for outpatient follow-up in the subsequent month. The Plan benefits terminated at the end of the first month as the result of a layoff. The patient postponed the outpatient until he had saved the cash to pay for it. The Union denied the inpatient claim despite the patient having complied with all other DC plans. Our challenge was that the Union was not entitled to Protected Information after their Plan no longer covered the patient. The interpretation of the lawyers was that a request for information after coverage terminates is not unreasonable for a month or two, but that a protracted requirement could be a violation of HIPAA.
Tuesday, November 10, 2009
One Lesson Learned
If an insurance company is allowed to stall the progress of an appeal for months through gross misrepresentation and incompetence, should they then be allowed to deny a claim for having maxed the prior year's benefits while the appeal was ongoing?
Value Options and Great West just did that and I am not sure why the government keeps giving these guys contracts, nor do I want to speculate on that. They initially denied a claim out-of-network and would not authorize the care despite the fact that they had no in-network facility within 80 miles. Appearing to have won the initial appeal, the claim was then stated to have been "pended" for a contract set-up problem. This was followed by: a billing issue; a dispute over which company was responsible to pay; and two months later denied as the patient had maxed their benefits a month after the treatment at our facility seven months earlier. We are still fighting this but one lesson learned is...
When appealing a claim, particularly one with a known day or dollar max, demand that the proceeds at issue be legally "pended" until all appeals and legal options have been exhausted.
Value Options and Great West just did that and I am not sure why the government keeps giving these guys contracts, nor do I want to speculate on that. They initially denied a claim out-of-network and would not authorize the care despite the fact that they had no in-network facility within 80 miles. Appearing to have won the initial appeal, the claim was then stated to have been "pended" for a contract set-up problem. This was followed by: a billing issue; a dispute over which company was responsible to pay; and two months later denied as the patient had maxed their benefits a month after the treatment at our facility seven months earlier. We are still fighting this but one lesson learned is...
When appealing a claim, particularly one with a known day or dollar max, demand that the proceeds at issue be legally "pended" until all appeals and legal options have been exhausted.
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