2-Year Old Health Ins. Claim?

jmcaa

We have a self-insured Health Plan. In the past there have been a couple of people who have called because they received a bill from a doctor/hospital from 1-2 years ago. The provider says they were never paid and the employee will be turned over to a collection agency if they don't pay up. What is our obligation when a provider either doesn't bill correctly or for some reason 1-1/2 years later says "Oops, I forgot to bill that".........Our Plan book says claims should be filed within the 12-month period following the date of service.

I had one former employee call me. She had to pay a $500 bill from 1999.

Anyone else had this problem?

Down_the_Middle

With some frequency we see this. Our self-funded plan does not pay claims after 12 mos and that sometimes results in the provider billing the employee. This is almost always due to poor office billing practices and when new staff are hired, they're asked to clean-up the old receivables. We instruct our employees to inform the provider that this claim is too old for payment and to adjust their records. If the provider continues billing the employee, usually the Dep't of Insurance steps in and stops the practice................ Your particular state may handle if differently, but that's a common practice. It's a real E/R's aggravant....

LindaS

I have had this several times in the past and our plan does not pay after 12 mos. unless it is determined that the error was on the part of the ins. company. Most times I have found it is due to the ee's failure to return some type of paperwork to the insurance company (subrogation questionnaire). In these cases it becomes the employee's responsibility to pay the outstanding bill.

Mentel

Check with your State Insurance Office. In Wisconsin, there is a limit as to how long a provider has to get a "good" claim in for processing.

NaeNae55

You might also want to remind your employees that if they go to a provider for services, they should notice if they get a bill or not. They should notice if they get an EOB (Explanation of Benefits) from the health plan or not.

In most cases a provider will write off the amount if it turns out that they failed to file a claim in a timely manner. But only some states have laws that require providers to do so, and not all providers will agree to write the amount off voluntarily. When they refuse to write the amount off, they usually argue that the patient knew they received services and should have noticed that it never got handled. Fortunately, those providers are few and far between.

Good luck!