The situation
A family called in October, a week before a court date for a lawsuit by a physician's
group. The previous December, their son had been admitted to a local hospital as an
emergency direct admit from the primary care physician's office. He had an infection
in his kidney and was passing blood. The pediatric nephrologist he used to see was
no longer in town. The only solution was to find an adult nephrologist who would take
a pediatric patient. They found one at UMC. What they didn't realize is that the group
the doctor belonged to, was not contracted with their insurance company, BCBS
PPO. In addition, BCBS had processed the claims as a regular admit, which was not
covered.
Tasks required
We received a copy of the legal papers from the attorney, contacted the physician
group, and told them an appeal was being filed with BCBS PPO. The physician group
agreed to suspend the legal action for 60 days pending the outcome of the appeal.
We obtained a copy of the medical records from the hospital, a copy of the request for
authorization from the primary care physician for the admit to the hospital (which had
a note that said an auth was not required for an emergency admission), a letter of
appeal from the primary care physician establishing the emergency situation. The
letter of appeal with all the documentation was hand-delivered to the local BCBS
office.
The normal appeal process is 30days and we heard back from BCBS in mid-
December that the claims were being paid and checks would be received within two
weeks. When the eobs came with the checks, we found that two claims had not been
reprocessed. We called the local rep we had been working with and she couldn't’t
explain how the two had been missed and reprocessed them while we were on the
phone.
Resolution/Outcome
By mid-January all funds had been forwarded to the physician's’s group. The original
bill was more than $6000, reduced now to the out of network benefit/emergency level,
and only $1500 remained as the balance due.
The ultimate patient/guarantor mistake is avoidance.
Had we gotten the phone call earlier in the year, all of the stress, frustration,
headaches and everything else that comes with ignoring bills, could have been
remedied. We now receive copies of all their medical bills, statements, etc., every
month. It usually takes just a few minutes to review them and return them with an
explanation of what needs to be done –don’t pay because the insurance company is
processing, okay to pay because insurance has paid and here is the balance due
from you.
A family called in October, a week before a court date for a lawsuit by a physician's
group. The previous December, their son had been admitted to a local hospital as an
emergency direct admit from the primary care physician's office. He had an infection
in his kidney and was passing blood. The pediatric nephrologist he used to see was
no longer in town. The only solution was to find an adult nephrologist who would take
a pediatric patient. They found one at UMC. What they didn't realize is that the group
the doctor belonged to, was not contracted with their insurance company, BCBS
PPO. In addition, BCBS had processed the claims as a regular admit, which was not
covered.
Tasks required
We received a copy of the legal papers from the attorney, contacted the physician
group, and told them an appeal was being filed with BCBS PPO. The physician group
agreed to suspend the legal action for 60 days pending the outcome of the appeal.
We obtained a copy of the medical records from the hospital, a copy of the request for
authorization from the primary care physician for the admit to the hospital (which had
a note that said an auth was not required for an emergency admission), a letter of
appeal from the primary care physician establishing the emergency situation. The
letter of appeal with all the documentation was hand-delivered to the local BCBS
office.
The normal appeal process is 30days and we heard back from BCBS in mid-
December that the claims were being paid and checks would be received within two
weeks. When the eobs came with the checks, we found that two claims had not been
reprocessed. We called the local rep we had been working with and she couldn't’t
explain how the two had been missed and reprocessed them while we were on the
phone.
Resolution/Outcome
By mid-January all funds had been forwarded to the physician's’s group. The original
bill was more than $6000, reduced now to the out of network benefit/emergency level,
and only $1500 remained as the balance due.
The ultimate patient/guarantor mistake is avoidance.
Had we gotten the phone call earlier in the year, all of the stress, frustration,
headaches and everything else that comes with ignoring bills, could have been
remedied. We now receive copies of all their medical bills, statements, etc., every
month. It usually takes just a few minutes to review them and return them with an
explanation of what needs to be done –don’t pay because the insurance company is
processing, okay to pay because insurance has paid and here is the balance due
from you.
Case Study
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