Lost in Paperwork Trail of Tears

[jkhtech]

What is the name of your state (only U.S. law)? California / Utah

My daughter went to a Residential Treatment Center (RTC) in Utah in the Spring of 2006, following a second life-threatening event that left the family paralyzed with no further local options available to help her. The California HMO plan that covered her did not extend to out-of-network, out-of-state care, so I was able to switch plans to a PPO. The RTC charged over $10K/month for their services for the following year that my daughter stayed there, paid out-of-pocket in advance. The RTC contracted with a billing company to handle insurance claims. Claims were submitted by the billing company directly to my insurance carrier. My PPO's Explanation of Benefits documentation noted that "out of network" claims for psychological treatment services were partially covered (40-70 percent, depending on the type). However, the claims were returned each month in "Pending" status, sometimes requesting "further documentation" (but not specifying what documentation was actually desired). In time, the claims were effectively denied, apparently, since nothing was paid for those claims. The final claim for a medical physical was paid to the RTC. As it turned out, the monthly claims submitted to the insurance carrier were all for "Room and Board" services, which would appear even to me to be nothing more than a Hotel bill. The facility was a certified Treatment Center, monitored by qualified medical staff, so the "Room and Board" claims seemed like an awfully weak attempt to get reimbursement! My company's insurance liason firm reviewed the paperwork and told me that the claims weren't likely to be paid, as submitted. Meanwhile, the RTC changed bill-handling companies. I no longer work for the same company, either, so my insurance carrier is no longer the same. I used up all retirement and savings to pay the RTC bills. Most of the other families I met through the RTC either had substantial personal wealth or government assistance. My family had neither. Additionally, questions were raised about "pre-approval" for the care we chose. I must have missed some small print in the contract, but I though that being able to choose providers and listed services was one of the big advantages of a full PPO insurance plan. "Pre-Existing Condition" was also not even asked about when starting this PPO.

My questions are: What should I do next? Can I rewrite and resubmit the poorly-worded claims? Should I sue the RTC for the funds the insurance carrier allegedly paid them? Or, perhaps I should simply crawl back under the rock I've apparenly been hiding under for more than two years? It's all a painful subject. At least my daughter is still alive, so the "do what it takes, at all costs" attitude that I had must have been worth it all! I didn't quite expect to come through this looking like such a fool, though.

[ecmst12]

Just because the plan is a PPO and has out of network benefits and does not require referrals, does not mean they won't have precertification requirements. It is quite normal for any inpatient stays which are planned and non-emergency in nature to require precertification from the insurance company.

[xylene]

You employed specialized medical treatment for your daughter.

The insurance denied the claim.

[moburkes]

I'm still stuck on how OP was able to switch insurance plans, unless it was open enrollment.

[jkhtech]

Originally Posted by ecmst12

Just because the plan is a PPO and has out of network benefits and does not require referrals, does not mean they won't have precertification requirements. It is quite normal for any inpatient stays which are planned and non-emergency in nature to require precertification from the insurance company.

Odd that the insurance company didn't EVER mention precert, and didn't actually deny based on any precertification requirement. I'd expect that to be one of their excuses for non-payment, however. Since my daughter was ALREADY IN TREATMENT at the RTC when we switched to the PPO carrier, I suppose some kind of PRE-EXISTING CONDITION argument could be raised, too, but it wasn't. I was simply presented with monthly "PENDING" statements for each claim that remained in the same status. Pardon my ignorance, but I simply wasn't aware that a precert could be required AFTER THE FACT. Wouldn't you think that I would have been informed of this, instead of simply being strung along with the vague possiblilty of reimbursement?

If the RTC treatment was "planned and non-emergency in nature" (which it certainly WAS NOT as far as anyone involved was concerned), shouldn't the RTC's billing people submit the appropriate paperwork. After all, THEY SHOULD KNOW what was required. That was their job. I was just the foolish parent who depended on the expertise of others.

[jkhtech]

Originally Posted by moburkes

I'm still stuck on how OP was able to switch insurance plans, unless it was open enrollment.

The insurance plan and carrier change was submitted as a "change in status", since my daughter went out of state for care, and as I mentioned, available care was exhausted by the local carrier. Appropriate, commercial Residential Treatment in California wasn't available.

This is probably what started us on such a slippery slope, since the local HMO carrier practically covered EVERYTHING from ambulance services, emergency room care, testing, and therapy sessions, to out-of-network (in California) temporary residential treatment. The HMO really did what they could, and it has a pretty vivid policy on precertification for even emergency services!

[jkhtech]

Originally Posted by xylene

You employed specialized medical treatment for your daughter.

The insurance denied the claim.

Specialized medical treatment? Yes, supposedly just as covered as the MANY OTHER medical treatments that the PPO covers. I supposedly could have chosen any of the treatments listed in my Policy and THEY WOULD BE COVERED as stipulated in the Policy with no more than a phone call and possibly a small form, in-network or otherwise. That's supposedly one of the main benefits of a PPO. You choose PROVIDERS. Insurance pays claims for the PROCEDURES as listed and in the amounts stipulated in the Policy.

Denied? Not really, at least not that I was informed. They just kept saying PENDING, then apparently dropped the ball.

My beef may well be with the billing company, who didn't seem to submit the claims correctly, or at least not with a billing code that meant anything to the insurance company. My question is, what can or should I do about it?

[xylene]

Originally Posted by jkhtech

My question is, what can or should I do about it?

Consult a specialist in insurance disputes and / or a bankruptcy attorney.

[Zigner]

Does your daughter have an IEP? If yes, what is her eligibility? Also, if yes, are you taking advantage of services through AB3632?

[lkc15507]

jktech,

There is a wealth of info in your post and I cannot make sense of all of it. Without being able to pinpoint better, I'm not sure exactly what to tell you. But, clarification would help. First, I also don't understand the change from HMO to PPO simply because in network services weren't available. That could be important in that you mention pre-existing conditions. How were you able to change plans?

Also, the pending status of the claims requesting more info, always places the insured in the position of being sure that the requested info is provided. Even if the EOB's were not clear to you, you likely should have pursued the matter to determine what was needed. However, I will point out that insurers are required to be clear. You simply need to utilize all of your appeals processes if something is not clear.

You also mention "room and board". All inpatient facilities charge "room and board". Those are the base rate charges that encompass the room, nursing care, and all ancillary personnel that do not / cannot charge for professional services. Also, do you know if the RTC met your plan's definition of a "hospital"?

As far as reconsideration of any unpaid claims, that all depends on the plan, the appeals procedures and whether you are within the appeals procedure time frame. You used the word "can" when asking. You can try anything including a lawsuit, but all of these unanswered questions I have will certainly have a bearing upon the success of any appeal, lawsuit, or whatever you pursue. I'm going to add that given the spring 2006 admission, it is not likely that you are within the appeals time frame, yet it is possible, especially considering that the claims were processed as pending information. lkc15507

[ecmst12]

Ok, I'll start with this: At what point did you call your insurance company's customer service dept to ask why the claims were still pending, what additional information was needed? What was their response? Did you then go back to the facility, tell them 'my insurance needs xyz info in order to pay your claim' so that they could get the problem corrected?

There is NO POSSIBLE WAY for any healthcare facility to know all the requirements for all the plans for all the patients that they see. There are simply too many. It is the PATIENT'S responsibility (or the parent, if it is a child) to know what their plan requires and make sure the requirements are met. You need to be proactive and not just assume that things are going to take care of themselves.

[jkhtech]

Originally Posted by moburkes

I'm still stuck on how OP was able to switch insurance plans, unless it was open enrollment.

As amazing as it sounds, this was simply applied as a status change. When an insurance plan no longer covers someone AT ALL (in this case, moved out of the limited coverage of the HMO-only company after the available in-network AND out-of-network resources were exhausted), we were allowed to change to the PPO plan that my company offered, which extended at least SOME coverage outside of California.

I'm glad that someone in charge allowed us to have insurance that could actually cover us. As it turned out, though, I wound up paying a lot more in premium costs for almost no coverage anyhow!

Apparently I wasn't proactive enough, even with a specially-contracted billing service AND an advocacy company supposedly on the case. Phone call inquiries were unproductive. I was expected to know more than the pros. Providers were expected to supply information, and my pleas didn't expedite the process.

The providers, billing company, and advocacy service all had nearly NO INCENTIVE to push my reimbursement claims along. The situation probably would have been much different if I hadn't first payed out of pocket for the care. If I only paid the anticipated co-pay amount, I'm sure that the process would have been much more decisive! Instead, it's as if the whole team were stalling until the claim time limit expired!

[jkhtech]

Originally Posted by Zigner

Does your daughter have an IEP? If yes, what is her eligibility? Also, if yes, are you taking advantage of services through AB3632?

No, we are not continuing further IEP actions. We got to the point in paperwork that would require me to relinquish parental rights for my daughter, and that wasn't a viable option! A major part of her trauma had been from prior experience as a ward of the state, so it would be senseless to go there again!

[jkhtech]

Originally Posted by ecmst12

Ok, I'll start with this: At what point did you call your insurance company's customer service dept to ask why the claims were still pending, what additional information was needed? What was their response? Did you then go back to the facility, tell them 'my insurance needs xyz info in order to pay your claim' so that they could get the problem corrected?

There is NO POSSIBLE WAY for any healthcare facility to know all the requirements for all the plans for all the patients that they see. There are simply too many. It is the PATIENT'S responsibility (or the parent, if it is a child) to know what their plan requires and make sure the requirements are met. You need to be proactive and not just assume that things are going to take care of themselves.

So much for relying on the professional services who HAD the information to actually do something productive with that info! The Provider's billing company was there for the purpose of meeting the billing requirements. I was assured that the answers would be supplied, once the billing company and I were sent the first Pending statement. I sent a detailed Explanation of Benefits to the billing company, and a full medical porfolio to my company's insurance advocacy service a few months later. It seemed silly or even counter-productive for me to submit my own reimbursement claims while a whole series of claims were in process, but bypassing the expected process seems like the only thing that I could do that I didn't (yet)!

[jkhtech]

Originally Posted by lkc15507

jktech,

There is a wealth of info in your post ...
...yet it is possible, especially considering that the claims were processed as pending information. lkc15507

If a claim remains in Pending status, am I allowed to dispute it? If a company is hired SPECIFICALLY to interpret and submit billing claims to insurance companies, is there any responsibility for job performance on their part? "Room and Board" shouldn't have been the ONLY charge submitted for several months, since there were numerous therapy sessions and treatments performed during her stay, but only the "lodging" was billed for several months.