My clients are told to contact me anytime they have a question about a claim, no matter how small.
Some remember that offer, some do not.
About a week ago I had an email from a client with a question about her policy. She had transitioned from a traditional copay plan with a $2000 deductible to a high deductible, HSA plan with a $10,000 family deductible.
Six weeks earlier her husband became ill while out of town on business. He was admitted through the ER into ICU where he spent 10 days, including several on a respirator. The onset of the illness was sudden and unlike anything he had experienced before.
The hospital Social Worker was assisting in contacting the carrier and had told my client she had a $20,000 deductible.
Going on the hook for $10,000 was bad enough, now she was told it would be $20,000.
Carriers are not allowed to communicate claim information to brokers such as myself so the only way for me to know about this is for a client to notify me, then ask.
I asked my client to send me copies of all correspondence and EOB's from the carrier as well as a signed HIPAA release. The release would allow the carrier to talk to me about current and future claims and do so with impunity.
Several phone calls and emails to the carrier and client have put me right in the middle. I have no problem with this, in fact, I told my client to attend to her husband and not to worry about the claim issues. I would handle it (as much as possible) and keep her in the loop.
As it turns out, the claim was first deemed out of network since her husband was in another state when the emergency arose. That issue has been addressed with the carrier and the out of network penalties will not apply.
Now comes the hard part.
Due to the diagnosis, a claim review was ordered. This is customary, regardless of the size of the claim, when a diagnosis is such that it could have been omitted in the initial underwriting stage.
Almost any illness related claim is subject to challenge and review when submitted during the first two policy years. Some carriers are more diligent in pursuit of pre-existing condition claims than others. Most of the time a cursory review is all that is needed before the claim is released for final adjudication.
But sometimes it is more detailed, and this is the case here.
The hospital stay alone is $88,000. Other bills for the ER, doctor, lab, etc will certainly push the claim over $100,000.
The review will generate a flood of inquiries to the doctors involved (six of them so far) as well as the hospital. Because providers are not always quick to respond to carrier inquiries, it will probably be another month before the review can actually begin. The actual review of data by the medical director will take another 3 weeks or so. I would not be surprised to see this claim extend into February before it is finally adjudicated and paid.
I have advised my client on what to expect and have asked her to keep me informed of any new issues as well as updating me on the health of her husband.
Out of this tragedy, there is some good news.
The out of network penalties will be waived which will minimize the out of pocket on this claim. I say minimize, because some of the providers are P.A.R.E. attendants who are usually not in any network.
We also refer to them as "hidden providers".
These are providers who are free to charge whatever they wish and balance bill the patient. This is one of the dirty secrets about health care that no one likes to discuss. Carriers do their best to hold down costs by having as many providers as possible in their network but they can't force any or all providers to join.
The other bit of good news is the carry over provision in the contract. Claims incurred in the last 3 months of the calendar year are allowed to carry over to the following year to satisfy the deductible. In this case, the $10,000 family deductible satisfies not only the 2008 deductible but 2009 as well.
A claim review is never fun or easy, but my clients know they do not have to walk that road alone.
Posts
0 comments:
Post a Comment