Wiki Termination of insurance appeal

[ahasson]

We've been getting multiple claim denials lately stating that the member's coverage was terminated, usually just a few days before the date of service. We go online to confirm their active status and call for benefits before or on the date of service. We try to appeal the claim and state that it should still be paid because they told us incorrect information about their coverage before the service, but our appeals usually get denied. Has anyone had any luck appealing these kinds of denials? There isn't anything else we could be doing on our end to confirm that the patient is definitely still active, that I'm aware of. Could I just be wording the appeals wrong? I feel that this is just the insurance company's issue and neither us nor the member should have to pay for the service, if they had told us originally that the member was active when we called them to verify it.

 

[CBLENNIE]

I work for an insurance company and it is not uncommon for the patient to show active at the time you looked up their information online or called the company for eligibility and benefits. Unfortunately, if the insurance is an employer sponsored plan it isn't uncommon for there to be a delay from the employer notifying us that an employee's cover is terminated retroactively. Another situation is for those who purchase their own insurance if they are late in paying their premiums and at the time you called they were in the grace period to allow the to pay without being terminated they may not make the payment and be retroactively terminated as well.

It is actually the responsibility of the patient to know if their insurance is active or not at the time of the service and provide you with that information. The insurance company isn't going to pay a claim for a member who received services after the termination of coverage no matter how many appeals you submit or how you word your appeal request.

 

[amyjph]

This is not something you should or could appeal. You are wasting your time appealing these. This would be like over drafting your checking account because you "thought" you had money yesterday, in the meantime you spent it, when you looked at your account the transaction had not gone through, so you spent more today.... Is that the bank's fault? Should they pay it for you? There is lag time as stated above by Corinne. It is up to the patient to give you the correct information at the time of service. Just because an automated call, rep call, or online portal says one thing, but then when you bill the service, it is found the member was not covered at the time of service, it's not going to be covered. They did not have insurance coverage... Bill the patient or call the patient to obtain the correct info or find out if they are self pay. I can't tell you how many times in RCM I had patients present insurance cards for coverage they knew they did not have or had lapsed/had not paid and we filed it only to be denied, then the patient did not pay their bill and went to collections for it. Unfortunately, when it is close to the termination date it is not always going to be known at the time of service.

You know that little disclaimer on every single payer call? "This is not a guarantee of payment, blah blah blah." Yeah, that's what this applies to, among other things. The member most certainly is responsible for this.

 

[ahasson]

Thank you for the advice, I am a new biller in a small office and I wanted to make sure I had the right advice going forward. I appreciate the help.

 

[Cls1530]

This is not something you should or could appeal. You are wasting your time appealing these. This would be like over drafting your checking account because you "thought" you had money yesterday, in the meantime you spent it, when you looked at your account the transaction had not gone through, so you spent more today.... Is that the bank's fault? Should they pay it for you? There is lag time as stated above by Corinne. It is up to the patient to give you the correct information at the time of service. Just because an automated call, rep call, or online portal says one thing, but then when you bill the service, it is found the member was not covered at the time of service, it's not going to be covered. They did not have insurance coverage... Bill the patient or call the patient to obtain the correct info or find out if they are self pay. I can't tell you how many times in RCM I had patients present insurance cards for coverage they knew they did not have or had lapsed/had not paid and we filed it only to be denied, then the patient did not pay their bill and went to collections for it. Unfortunately, when it is close to the termination date it is not always going to be known at the time of service.

You know that little disclaimer on every single payer call? "This is not a guarantee of payment, blah blah blah." Yeah, that's what this applies to, among other things. The member most certainly is responsible for this.

Very well said!