Wiki insurance retro terminated coverage

[JesseL]

How do you handle situations where at the time of service, patient had active coverage.

After the claim is finalized, you find out the insurance retro-terminated/back dated their coverage.

Most patient don't pay when that happens and blames the provider and not sort out their insurance.

I had tried to appeal these with proof that when insurance was checked, we saw active coverage to no success.

 

[liloe517]

It would be patient responsibility. It is the patient's responsibility to know their insurance coverage. When eligibility is checked it tells us that it is not a guarantee of payment.

 

[thomas7331]

I agree. A coverage termination is entirely between the patient and their insurance - the provider has no control over this. There is nothing to be gained from sending an appeal and doing this will only delay things. The best practice is to go directly to the patient when this happens and find out what their correct coverage is, if they have any. Many practices also use some kind of a financial responsibility agreement that patients sign - if you have something like this, you remedy the situation of a patient 'blaming' the provider and not paying by making it clear to them that they were notified that they will be responsible for this if the insurance does not cover them.

 

[Cavalier40]

To me it depends on why it termed.

If it was an ACA exchange policy or individual policy, we attempt to check for proof of premium payment (although some payers will not give that information, but some will tell you if they are in the non payment grace period). Same with COBRA.

If the policy was employer based and not COBRA and a decent amount of time has passed, then you can appeal based on the bad actions of the employer not communicating the termination of coverage in a timely manner. I once had a payer try to take back payment on a patient who has 2 admissions about 6 months apart. The retro term was dated before the first admission. Since the policy was self funded, I appealed based on the fact the my facility acted on good faith and that the manager of the fund did not act in good faith. This appeal worked and saved a $100k payback.

The majority of cases are not like that, but there is a provision in our financial agreement that misrepresentation of coverage will result in the account going to collections 30 days after the statement is issued.

I wish there was a law that put the responsibility on reporting eligibility for coverage on the payer.

 

[JesseL]

To me it depends on why it termed.

If it was an ACA exchange policy or individual policy, we attempt to check for proof of premium payment (although some payers will not give that information, but some will tell you if they are in the non payment grace period). Same with COBRA.

If the policy was employer based and not COBRA and a decent amount of time has passed, then you can appeal based on the bad actions of the employer not communicating the termination of coverage in a timely manner. I once had a payer try to take back payment on a patient who has 2 admissions about 6 months apart. The retro term was dated before the first admission. Since the policy was self funded, I appealed based on the fact the my facility acted on good faith and that the manager of the fund did not act in good faith. This appeal worked and saved a $100k payback.

The majority of cases are not like that, but there is a provision in our financial agreement that misrepresentation of coverage will result in the account going to collections 30 days after the statement is issued.

I wish there was a law that put the responsibility on reporting eligibility for coverage on the payer.

This patient in particular was under a Medicaid managed plan.

Likely screwed up their own medicaid re-enrollment paper work.

Unfortunately most of our patients, like this one, are from another country with limited to no English and of course have zero understanding of insurance.

They're the most difficult to deal with when it comes to these things, asking them to fix their insurance is like asking them to climb a mountain.

Sending them to collections means nothing to them either because they generally do not care about their credit score.

I agree there should be a law that the insurance should be held accountable when providing misinformation.