coordination of benefits - maryland

[stampoutspam]

Hello, I live in Maryland. I already posted this on the 3rd but I don't think it worked...so I'm posting again.

Before I go into details, a little info:
Primary insurance (thru my employer): Aetna PPO
Secondary insurance (thru husband's employer): Client First (managed by Maryland Benefit Administrators, Inc)
Date of service: 11/6/2006
Amount: $600

I'd like to find out more about how Coordination of Benefits work. Does each insurance company get to define their own rules? Or is there a federal (or state) guideline that must be followed?

Aetna received the bill for $600, declared the UC (usual and customary) cost to be $214, and paid $171.20 towards the bill - leaving a balance of $428.80.

Client First received the bill and only paid what was remaining of the UC amount declared by Aetna ($42.80). This still leaves me with a balance of $386.00 to pay.

I ran into a similar situation back in 2004 when I had a surgery - but the circumstances were slightly different (my secondary was a COBRA plan I kept from a previous employer). My secondary was only willing to pay what was left of the UC amount after my primary had paid. I made lots of calls, emails and letters - and finally found someone who told me "oh, I see what they've done...they're making payment as if your primary and secondary are 'integrated'...but they SHOULD be paying according to 'coordination of benefits'." Once they figured this out, all of my bills got paid.

Now it seems like I'm going thru the same thing again. Does anyone know the difference is between integrated and coordination of benefits? Is Client First correct? Do they only have to pay $42.80 even though the UC cost is much higher??? This just doesn't seem right. Should I contact a lawyer? Or is there some guideline I can quote to back me up?

I should mention - this is a really big deal b/c the $600 bill was only a small part of a surgery I had done. My total bills are around $50k. So PLEASE help.

Thanks,
Amanda in Maryland

[cbg]

This is the way primary and secondary insurance generally works.

The bill is submitted to the primary carrier and they pay their portion.

The bill is then submitted to the secondary carrier.

The secondary carrier determines what they would have paid IF they were the primary carrier.

They pay the difference between what they would have paid if they were primary, and what the primary carrier did pay.

This means that unless they would have paid significantly more as primary than the primary carrier did, the insured can still end up with payments to make. It can sometimes mean that the secondary carrier pays nothing at all.

Now, I"m not going to say there can't possibly be any other ways for two carriers to coordinate. It's determined by the contract/policy, not by law (either Federal or state). But the way I have described is by FAR the most common.

Unfortunately, many people wrongly assume that a secondary carrier will pay any balances not paid by the primary carrier, and that is just not the case 99.99% of the time.

[stampoutspam]

So, it MAY benefit me to have the secondary determine THEIR UC cost, right? Because if they determined it to be more than the primary's then they'd make more of a payment...

So I am assuming I should ask them for a copy of the policy? I probably wouldn't be able to find it at home. Would the policy outline how they handle COB?
Thanks,
Amanda

[cbg]

Yes, it might benefit you to have them determine their UC cost. However, you need to keep in mind that it could as easily be LESS than Aetna's.

You definitely should see what the policy says, and in view of the above, you should do it before you ask the secondard carrier to do anything.

[stampoutspam]

lol. Well, if it WAS less than Aetna's UC, I sure hope they wouldn't expect a refund from me!

[cbg]

This is why I'm suggesting that you find out what the policy says before you take any further action. No sense rocking the boat.

[ecmst12]

Of course, what will save you the MOST money would be using doctors that are in Aetna's network, then you don't owe anything over the contracted rate that aetna pays a percentage of. It sounds like your secondary insurance pays the percentage that Aetna does not pay, so you'd end up owing nothing! Pretty good deal