Insurance takeback on hospital bill (2 years)

[ab1]

What is the name of your state (only U.S. law)? Indiana

Greetings! I am hoping someone can help me understand my options in this case.

Two and a half years ago (10/07), my wife gave birth to our son. Following the hospital visit, my insurance (Anthem) paid the claim and all was well. I applied a bit more diligence and contacted both the hospital and insurance by phone to confirm that my balance was zero, and I moved on.

Today, some two and a half years later, I recieved a bill from the hospital showing the original total charges, the original negotiated insurance amount, and the original anthem payment....below this however it shows a takeback from Anthem on 1/14/10, a new lower insurance payment, and a substantial balance for that I am instructed to pay immediately.

The hospital said that the insurance made a mistake and now I owe the balance. Can they really come back after all of this time and charge me the balance. Do I have any option in this matter? I am waiting for a callback from the insurance company, who I am no longer with by the way.

Thanks in Advance! ab1 - Indiana

 

[lealea1005]

What is the name of your state (only U.S. law)? Indiana

Greetings! I am hoping someone can help me understand my options in this case.

Two and a half years ago (10/07), my wife gave birth to our son. Following the hospital visit, my insurance (Anthem) paid the claim and all was well. I applied a bit more diligence and contacted both the hospital and insurance by phone to confirm that my balance was zero, and I moved on.

Today, some two and a half years later, I recieved a bill from the hospital showing the original total charges, the original negotiated insurance amount, and the original anthem payment....below this however it shows a takeback from Anthem on 1/14/10, a new lower insurance payment, and a substantial balance for that I am instructed to pay immediately.

The hospital said that the insurance made a mistake and now I owe the balance. Can they really come back after all of this time and charge me the balance. Do I have any option in this matter? I am waiting for a callback from the insurance company, who I am no longer with by the way.

Thanks in Advance! ab1 - Indiana

Anthem probably conducted an internal audit and found the error on their part, then took the money back from the hospital by deducting the amount from another patient's payment. Unfortunately, it's not unsual for this to happen and is frustrating to the providers as well. You do owe the amount.

 

[kienich]

Anthem bill 2 years later

The same thing just happened to me. I had surgery Feb of 2009 and received an adjusted statement from Anthem two weeks ago and now a bill from the hospital for almost 2k. It seems wrong that they could bill you two years later or that the insurance company could change benefits two years later. Very frustrating.

 

[cbg]

It's not a question of changing benefits; it's a question of their discovering that they paid incorrectly in the first place.

 

[lkc15507]

I don't think these scenarios are quite right to me. I don't know IN state law and 2nd poster does not list state. However, over 2 years (at least in the first case) seems excessive for the insurer to be able to make an adjustement to claims payment (and thereby request refund / adjustment from the provider, which then results in balance due from insured). For example, in my state, that is limited to 1 year. In any case, fed law requires the insured to be notified by the insurer of any adverse determination. Neither of these posters have mentioned any notification of such. I would definitely check state law and contact the insurer.
Best, lkc15507

 

[lealea1005]

I don't think these scenarios are quite right to me. I don't know IN state law and 2nd poster does not list state. However, over 2 years (at least in the first case) seems excessive for the insurer to be able to make an adjustement to claims payment (and thereby request refund / adjustment from the provider, which then results in balance due from insured). For example, in my state, that is limited to 1 year. In any case, fed law requires the insured to be notified by the insurer of any adverse determination. Neither of these posters have mentioned any notification of such. I would definitely check state law and contact the insurer.
Best, lkc15507

The patient and provider are considered "notified" when they receive the corrected EOB. For the provider, the amont is automatically deducted from other patient's payments on that EOB. For the patient, The EOB will indicated the adjusted amount owed, along with an explanation indicating the change in determination is due to an "internal audit" or "internal rule".

 

[lkc15507]

The patient and provider are considered "notified" when they receive the corrected EOB. For the provider, the amont is automatically deducted from other patient's payments on that EOB. For the patient, The EOB will indicated the adjusted amount owed, along with an explanation indicating the change in determination is due to an "internal audit" or "internal rule".

1) The poster says nothing about having received a corrected EOB.
2) Such an EOB would have been required within mandated time frames, most likely 1 year.
3) Poster states his/her 1st awareness was some 2 years later via a "bill", not an EOB.
4) That is not proper notice of adverse determination by the payer.
5) I think my post is self-evident that I understand when they are properly notified.
6) I don't care what "internal" whatever revealed the error, adjustments/refunds must still be timely.
7) What part of "neither poster mentions notification of such" didn't you understand?

My response is based upon what the poster stated. It is entirely possible that the poster was properly notified of adverse determination within accepta ble time frames. Thus my response is that the scenario does not seem quite right and he/she is advised to contact the payer (to spell it out for you) - in order to determine what their records indicate.

 

[ecmst12]

That doesn't mean an EOB wasn't sent but ignored or mistaken for junk mail...

 

[lkc15507]

Precisely. "The dog ate it", just doesn't cut it when it comes to health insurance payments / notificaitons etc. Perhaps I was not crystal clear in the first post, but my intent is to demonstrate that both posters need to investigate the origins of the error. Yes, an error exists because they are now on the hook for money they didn't thlink they should be. Perhaps my first response implied the payer to be at fault, but that was not at all my intent. My intent is to simply get folks to be aware of their responsibility and hopefully provide useful information to get them there.

 

[lealea1005]

[

QUOTE=lkc15507;2726654]1) The poster says nothing about having received a corrected EOB.

True, but that doesn't mean s/he didn't get one and ignore/discard it (as already stated by ecmst).

2) Such an EOB would have been required within mandated time frames, most likely 1 year.

A year after the corrected determination would be considered "timely". A bill sent after receipt of corrected determination would obviously follow the provider's receipt of the corrected EOB..

3) Poster states his/her 1st awareness was some 2 years later via a "bill", not an EOB.

As already stated, we don't know if OP received and discarded/ignored and EOB before receiving bill.

4) That is not proper notice of adverse determination by the payer.

I agree it's not "proper", but it is not illegal.

5) I think my post is self-evident that I understand when they are properly notified.

Alrighty then, and I do as well.

6) I don't care what "internal" whatever revealed the error, adjustments/refunds must still be timely.

According to the insurance companies I deal with, and there are many,they have up to 2 years from the DOS to audit claims and apply corrections.

7) What part of "neither poster mentions notification of such" didn't you understand?

My response is based upon what the poster stated. It is entirely possible that the poster was properly notified of adverse determination within accepta ble time frames. Thus my response is that the scenario does not seem quite right and he/she is advised to contact the payer (to spell it out for you) - in order to determine what their records indicate.

Ummmm...wow.

Simply stating the FACT that (as a provider), most times, our first and only "notification" comes via the corrected EOB with the amount already deducted from our bulk payment. Getting such a notification 2 years after initial determination and payment is not unheard of (our office got at least 4 last year for services rendered in 2008).

Believe me, it does not make my day when I receive such a notification and am left to track down the patient to attempt collection for services rendered 2 years prior.

I hope Op does contact the payor.....and pays his/her bill.

Have a nice day.

 

[ajkroy]

I'd also like to add that errors are obviously made and I would advise the OP to investigate their benefits along with the payment with a fine-toothed comb. The insurance made a mistake once...it doesn't mean they are correct this time, either. Don't just take their "word" for it.

 

[lkc15507]

[

True, but that doesn't mean s/he didn't get one and ignore/discard it (as already stated by ecmst).



A year after the corrected determination would be considered "timely". A bill sent after receipt of corrected determination would obviously follow the provider's receipt of the corrected EOB..



As already stated, we don't know if OP received and discarded/ignored and EOB before receiving bill.



I agree it's not "proper", but it is not illegal.



Alrighty then, and I do as well.



According to the insurance companies I deal with, and there are many,they have up to 2 years from the DOS to audit claims and apply corrections.


Ummmm...wow.

Simply stating the FACT that (as a provider), most times, our first and only "notification" comes via the corrected EOB with the amount already deducted from our bulk payment. Getting such a notification 2 years after initial determination and payment is not unheard of (our office got at least 4 last year for services rendered in 2008).

Believe me, it does not make my day when I receive such a notification and am left to track down the patient to attempt collection for services rendered 2 years prior.

I hope Op does contact the payor.....and pays his/her bill.

Have a nice day.

Your response boggles me brain. I think I stated that before ecmst did, not to mention my following bullet points futher expand on this topic.


Me brain remains boggled. The whole point is that there is no evidence of a "timely" "corrected determination". Certainly the "bill" sent afterward would be valid but only if the (missing evidence of) "timely" "corrected determination" was received by both provider and insured. I am convinced at this point your viewpoint is that of a provider. Ya'll conduct internal reviews when it suits you. Providers routinely do NOT consider the time frames defined by a payer plan. Certainly you can collect a debt up to 7- 10 years from the insured. What you are not realizing is that those same collection statutes do not apply to an insurer.

No dispute. I've state this already. My post is intended to direct the posters to make that determination in each of their situations.

????? Who the freak thought, much less used, that term "illegal" before now?
Brain super boggled now.

Thank you.

Entirely possible. Please, please re-read all my posts. This is why I refer posters to applicable state law. (Fed law may apply, but I am infering from posts that these are likely fully insured plans in which case state laws apply.)

lealea, I have not a doubt one that in practice, 2 years or more may be commonplace. As already stated, it may be considered timely in some states as I certainly do not know regs for 50 states. But, I suspect that if untimely notifications from a payer are recognized / allowed by a provider, it has much more to do with network contracts than applicable regulations. That ultimately leaves the insured in the lurch.

Believe me, it does not make my day when a client contacts me having been sent to collections in these scenarios. I get to tell them frequently enough they were timely notified by payer, but I can't expain why provider took two years to bill.

I do too. Regardless what some may have assumed from my posts, I suspect the posters were likely notified of adverse determination. Payers don't screw that up very often. I see it all the time. But, for the benefit of the posters, my posts are intended to help them find the info they need to know where the fault lies.

 

[lealea1005]

The whole point is that there is no evidence of a "timely" "corrected determination". Certainly the "bill" sent afterward would be valid but only if the (missing evidence of) "timely" "corrected determination" was received by both provider and insured.

Missing evidence?

OP#1 received services in Oct. 2007. Claim was paid by BCBS (Anthem) within a reasonable period. OP called hospital to make sure balance was zero. On 1-27-10, OP gets a bill, with a correction from Anthem dated 1/14/10, from the hospital. OP gets hospital bill within 13 days of EOB's date. How is this not "timely" on the hospital's (provider) part?

OP#2 (who should have been told to start his own thread) receives services February 2009. He gets the adjusted EOB from Anthem 2 weeks ago and now a bill from the provider. How is this not "timely" on the hospital's part?

The payor's (insurance company) audit found a mistake in the way they originally paid the claim. They have 2 years to perform the audit. Perhaps you can get a provider to let you read the clause in their insurance company contract which points out they are permitted to audit claims up to 2 years after initial payment/determination. Oops, nope, no can do....the Docs risk being sued by the insurance company if they allow anyone to look over their contract.

I am convinced at this point your viewpoint is that of a provider.Ya'll conduct internal reviews when it suits you.

What the heck are you talking about?? Providers do not conduct the internal audits...the insurance companies do.

Providers routinely do NOT consider the time frames defined by a payer plan.

Actually, the providers are bound by the parameters of their contracts with the insurance companies (payors), or risk losing their contracts.


I think you're misundertanding. I, in no way, think waiting 2 years after receiving determination (EOB) to bill a patient their portion is "timely". The providers referred to by both OP's billed within days of receiving the corrected EOBs from the insurance companies. They just happened to arrive 2 years after the dates of service AND after the initial claim was already paid.

Sorry your mind is boggled, that was not my intent. I find a little hot tea with lemon helps.