Third Party Administrator problems

[TxsMama]

i live in tx. my husband had insurance coverage through his employer. his premiums were payroll deducted. last summer he went to the dr. twice. in december, we received bills from both visits with a letter that indicated the ins. co. was not responding or paying our claims. the drs. also filed complaints w/the tx dept of ins.

here are the nuts and bolts of it...the ins. plan was self-funded by his employer, which puts them under the ERISA act. i understand this pre-empts state regulation of self-funded plans.

the dept of ins. send a letter the the tpa, pga management systems, and here is their response...
"we are not an insurer, nor are we subject to tx ins. code article 21.55. it is a contract administrator under contract w/valiant administrators corp. whose functionis to provide srevices through medical trusts formed under the provisions of erisa and operating out of the district of columbia."

they forwarded the communication to valiant. "payment has been effected. the explanation of benefits are attached."

i received eob's for both visits. I called the drs. to see if these had been paid. they had not, so we paid them.

my gripe is...i want my money back. they had no problem taking the money out of my husband's paycheck, but they can't pay two simple claims. we paid our co-pay, and expected them to pay their part.

do i have any recourse?

i have also filed complaints with whoever would listen to me.

 

[cbg]

What was the reason given on the EOB for the denial? Not a covered benefit, exceeds plan limits, what?

 

[TxsMama]

that's the thing, the claim was not denied. on the eob under payment info it shows where they have made a pmt. to the dr. but left off the date and check number, when they have not made a pmt. at all. under the patient's responsibility, it show what we have paid as far as co-pays and amt. not covered.

as i indicated earlier, we went ahead and paid the bills to avoid bad credit info.

 

[cbg]

Have you spoken to anyone at your husband's employer? Benefits, HR? This is really strange. I've worked for a TPA, I've worked for an insurance carrier and I'm currently in HR and this makes no sense. The HR or Benefits person who handles the policy (it would be me in my company) sometimes has special contacts that can help sort things out. Have you gone that route at all?

 

[TxsMama]

I have done all of that. I called the company he worked for, and they gave me the number to PGA. I spoke with a lady there, and she said they would get the claims paid. Then in January, I called again to request a COPC, and they sent that.

When I found out that the claims still had not been paid, I tried calling them again at the end of January, and all I got was an answering machine, and no way to speak a person. It's like they
are avoiding everyone at all costs.

I promise, I am telling the truth about all of this. It came up, and bit us in December. My husbands dr. visits were in June. I don't know what else to do, but I will fight this.

 

[cbg]

I'm not saying you aren't telling the truth, just that even with experience in all of the various areas of your complaint, I am totally bamboozled by this. You said you'd talked to the insurance commissioner, right? If not, do that. If so, I think you're going to need a lawyer.