Secondary EOB stating -0- balance

[kellyroko]

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

I have two separate health insurance coverages: Primary is United Healthcare (EPO) and secondary Humana (PPO).

My dependant daughter had pre-authorized surgery in January. The bill was filed with UHC for $6099.35. After their "provider's discount," they paid $2626.20, leaving me with a balance of $541.80 to pay.

It was then submitted to Humana. Humana processed the claim. The total allowable amount under Humana's contract was only $1977.00, leaving my portion at -0-. I received the EOB from Humana stating a -0- responsibility.

The hospital system has billed me and claims that I am responsible for the amount that remains from my primary ($541.80) because Humana is being billed as my "SECONDARY" insurance. The way that it has repeatedly been explained to me by Humana is that Humana's contracted price MUST be recognized by the hospital system according to the contract and therefore, I owe nothing.

The hospital has also tried to tell me that they are not "contracted" with any secondary insurances. They have also reminded me that I signed a paper stating that if the insurance company didn't pay, I was responsible (again, this is negotiable since Humana DID pay hypothetically (with a lower contracted price) - I have the EOB).

Now, I suppose that I should have just folded by now and accepted the hospital's GRACIOUS offers of a 40% reduction and a payment plan, but the fact is I pay to have the contracts of BOTH insurances - so it would make sense that I would benefit, especially if Humana says it's in their contract - from Humana's contract. Sidebar - I have no way of varifying the contract between the Humana and the hospital, so it feels like I'm fighting with half-****ed guns.

I do not know what to do, and have been totally unsuccessful in figuring out who my advocate is. I don't know where to turn and am unfortunately still awaiting a bill from the same hospital system (trust me, this will be the last! I will use another hospital system that has never given me this problem next time) for another surgery on another child that happened before all of this fiasco.

Should I hire a lawyer and ask for court/lawyer fees?

[cbg]

No, what you should do is read the coordination of benefits sections of your policies before you jump to the conclusion that the secondary carrier will pick up any balances due.

The fact of the matter is that unless the secondary carrier has significantly better benefits than the primary, it is IMHO a waste of money to carry two policies.

If you had asked this question before the surgery I would have told you that this was what was going to happen.

[kellyroko]

Originally Posted by cbg

No, what you should do is read the coordination of benefits sections of your policies before you jump to the conclusion that the secondary carrier will pick up any balances due.

The fact of the matter is that unless the secondary carrier has significantly better benefits than the primary, it is IMHO a waste of money to carry two policies.

If you had asked this question before the surgery I would have told you that this was what was going to happen.

I don't understand how you could possibly have told me this would have happened. Fortunately, this is the ONLY hospital chain that has denied this coordination of benefits between United and Humana.

Also, I have read the coordination of benefits on BOTH policies and fully understand primary and secondary. Where there seems to be debate is in the contract between Humana and the hospital. Perhaps I didn't make myself clear on my situation.

Humana has stated that I owe NOTHING because of the coordination of benefits. It is the hospital that is insisting I do.

[ecmst12]

Then you need to have HUMANA contact the hospital on your behalf.

[kellyroko]

Humana has contacted the hospital (I have names and dates) and were told that the balance was adjusted to the contracted amount and that I owe -0-. On two separate occassions, the hospital chain then came back to me and told me that after submitting the agreed changes, they were over-ridden and that I am, once again, responsible for the balance.

All very frustrating. The EOB (that the hospital has a contract with but is ignoring) states that I have -0- responsibility. Unfortunately, if I just ignore the hospital bills, they will doubtlessly go to a collection agency. Then it's a new battle to show that I don't owe anything.

Has anyone ever successfully claimed insurance fraud against a billing provider in this type of situation?

[ecmst12]

The only entity that can enforce the contract is the entity that it is with - your insurance company. They need to be more forceful with the hospital.