Check Your Wallets!

Lisa in Katy · Apr 8, 2009

Okay everyone, it's April 8. We are over 3 months into this year. Please check your wallets. Are you carrying your latest and greatest insurance card?

I'm dealing with 2 issues today where members went into the same hospital in early February for outpatient procedures and presented their old cards. The hospital apparently didn't verify benefits and the claims were denied because the members are no longer covered under that plan. Guess what? The claims were denied by my company as well because for these particular procedures (MRIs) the hospital is required to notify us in advance, which they didn't do because they didn't know we were the appropriate plan. So what's going to happen? The member will be billed for full charges. They can argue that the hospital didn't do what it was supposed to do because of the non-verification, but in truth, it is the member's responsibility to present accurate information, so there is shared responsibility.

So again, take out your wallet and look. Are you carrying your current card? In this case the member will go from owing $100 to over $1000. Hopefully they can play "Let's Make a Deal" with the hospital.

Ross · Apr 8, 2009

Wallet? What wallet? I'm waiting for a bail out.

sheridan07 · Apr 8, 2009

I had that happen and the doctor's office just resubmitted it for me and the insurance payed their part.

Lisa in Katy · Apr 8, 2009

Brian, in most outpatient situations that is what will happen. But for some procedures, specifically high dollar procedures and outpatient surgery, insurance companies have guidelines that the provider has agreed to follow, and if they are not followed, the claim will deny, at least in part. (We actually denied only 50% of the allowed amount on the claims I mentioned, as that is the penalty for non-notification).

In inpatient situations, almost every plan requires notification either up front, or within 24-72 hours of admission. So, if the hospital doesn't know who to correctly notify, the claim will deny.

I doubt there are many hospitals who fail to verify benefits in non-emergency situations, but it does happen occasionally. It probably depends on how busy they are and how much training the intake clerk has.

sheridan07 · Apr 8, 2009

Lisa in Katy said:
Brian, in most outpatient situations that is what will happen. But for some procedures, specifically high dollar procedures and outpatient surgery, insurance companies have guidelines that the provider has agreed to follow, and if they are not followed, the claim will deny, at least in part. (We actually denied only 50% of the allowed amount on the claims I mentioned, as that is the penalty for non-notification).

In inpatient situations, almost every plan requires notification either up front, or within 24-72 hours of admission. So, if the hospital doesn't know who to correctly notify, the claim will deny.

I doubt there are many hospitals who fail to verify benefits in non-emergency situations, but it does happen occasionally. It probably depends on how busy they are and how much training the intake clerk has.

I'm sorry that this is happening to you. Mine happened when I was seeing the PCP at his office. I thought calling the hospital might help, so I'm sorry.

Lisa in Katy · Apr 8, 2009

sheridan07 said:
I'm sorry that this is happening to you. Mine happened when I was seeing the PCP at his office. I thought calling the hospital might help, so I'm sorry.

Actually, it's not happening "to" me. I work for the insurance company!