Health Insurance Claim Dispute

[holdem31]

What is the name of your state? IL

i had emergency appendenctomy in early october 2006, my insurance paid the claims in december 2006 and then i recieved a letter in late april 2007 that said.."during a routine investigation of your file, we see this procedure was related to a pre-exsisting condition and thus we will be pulling back all your claims and denying benefits."

can they do this? they already paid the claims and then 5 months later they are denying them. I would have thought they would review the file before the pay the claim.

do the providers have to refund the insurance company the money? will the insurance company make me pay them back? i need some good advice! thanks in advance

[ecmst12]

Yes they can do this, but there is probably a procedure to appeal if you do not believe you had a pre-existing condition. Yes, your doctors will have to pay them back and yes, they WILL come after you for the money.

[lealea1005]

Originally Posted by holdem31

What is the name of your state? IL

i had emergency appendectomy in early October 2006, my insurance paid the claims in December 2006 and then i received a letter in late April 2007 that said.."during a routine investigation of your file, we see this procedure was related to a pre-existing condition and thus we will be pulling back all your claims and denying benefits."

can they do this? they already paid the claims and then 5 months later they are denying them. I would have thought they would review the file before the pay the claim.

do the providers have to refund the insurance company the money? will the insurance company make me pay them back? i need some good advice! thanks in advance

By the time you received your letter, the insurance company most likely automatically took their payment back from the Physician by debiting other patient payments. Expect a bill from your Physician and/or the hospital in the near future. Yes, it is now your responsibility to pay it.

As Ecmst12 stated, you can always appeal the decision. Call the hospital and Physician and ask whether they would be willing to wait for the appeal decision, but don't hold your breath. You can always offer to make regular payments while awaiting the appeal decision. They are probably just as surprised/perplexed at the decision as you are.

Good luck to you.

[holdem31]

i guess im just suprised that the providers would be so willing to just remiburse the health insurance after the claims have already been paid for 4 months. Its kind of ironic, i actually work in subrogation/recovery business for health insurance and there are so many laws and sometimes we can even recieve duplicate payments or go after duplicate payments to providers (paid by auto ins. ect) ...wish me luck on my appeal

[lealea1005]

Originally Posted by holdem31

i guess im just suprised that the providers would be so willing to just remiburse the health insurance after the claims have already been paid for 4 months. Its kind of ironic, i actually work in subrogation/recovery business for health insurance and there are so many laws and sometimes we can even recieve duplicate payments or go after duplicate payments to providers (paid by auto ins. ect) ...wish me luck on my appeal

Believe me, we aren't "willing to just reimburse". We have no choice and no opportunity to question it. They automatically debit the payments for services rendered to other patients who have the same insurance as yours. That way, they are guaranteed of getting their money back immediately. Our oldest retroactively denied/reimbursed claim was over 2 years old.

Best of luck with the appeal. Come back and let us know how it went.