Double Health Insurance Nightmare & Potential financial ruin ... Please help with advice

[cavediver]

But I have medical insurance for her, I cannot understand how I will end up having to owe money out of pocket for this. It blows my mind of complicated stuff is here. I'm a german citizen living in the US and really don't understand the logic in this.

I guess the best I can do is this:
1. Contact Kaiser and talk to them about this
2. Contact all the doctors that we ever used and let them know to submit the claims to Kaiser directly instead (I doubt any of them accept Kaiser, so I guess I have to do it manually) which these claims are likely to be rejected since those doctors aren't covered by Kaiser
3. Once we receive the EOB and rejection submit it to UHC for secondary
4. Pray that UHC won't reject it for whatever reason, they covered it so far so I'm not sure why they wouldn't but it sounds like they could ...

 

[LostDollar]

But I have medical insurance for her, I cannot understand how I will end up having to owe money out of pocket for this. It blows my mind of complicated stuff is here. I'm a german citizen living in the US and really don't understand the logic in this.

I guess the best I can do is this:
1. Contact Kaiser and talk to them about this
2. Contact all the doctors that we ever used and let them know to submit the claims to Kaiser directly instead (I doubt any of them accept Kaiser, so I guess I have to do it manually) which these claims are likely to be rejected since those doctors aren't covered by Kaiser
3. Once we receive the EOB and rejection submit it to UHC for secondary
4. Pray that UHC won't reject it for whatever reason, they covered it so far so I'm not sure why they wouldn't but it sounds like they could ...

I can't tell from the prior comments. Does the Kaiser insurance policy allow any payment to be made to doctors outside of the Kaiser network?

 

[cavediver]

I can't tell from the prior comments. Does the Kaiser insurance policy allow any payment to be made to doctors outside of the Kaiser network?

I'm not 100% sure. I wanted to figure out the next logical steps to take before reaching out to all parties to make sure I'm approaching this with the best knowledge and plan I can

 

[leevena]

I wish our benefits coordinator would have that info ... I'm trying to contact her and ask for advice navigating this issue but all she response is that I cannot make changes outside of enrollment periods which has nothing to do with what I'm asking help with ...

Do you have any advice how to best start cleaning up this mess? Call both insurers and figure it out, get a lawyer, trying to get a court order or something similar to get her Kaiser insurance to post-term coverage?

I started my career in 1982, always on the group side. Your appeals will fall on deaf ears, short of some miracle. You and your wife were both provided with the COB rules by your respective employers ( see your spd) and the benefit person should not be providing you with advice on how to proceed. If she is wrong, it opens her to liability. Best bet is to submit to Kaiser, if you have not (I assume you have) and negotiate a payment plan. Sorry

 

[Yagents]

I can't tell from the prior comments. Does the Kaiser insurance policy allow any payment to be made to doctors outside of the Kaiser network?

since your not licensed or experienced in this business, why do u contribute? Kaiser is HMO with no OON

 

[LostDollar]

I am not an insurance agent, just a consumer that happens to be a forum member.
My knowledge is limited to experience with my own family's group health plans.

American insurance companies have a set of rules defining "Coordination of Benefits" (COB). Those rules include defining which insurance company is the "Primary" insurance carrier and which company is the "Secondary" insurance carrier in situations where a person is covered by more than one insurance policy.

An employee can have single coverage or family coverage. If an employee has health insurance from their own employer, that is always "Primary" insurance for them. If an employee covers their spouse under a family plan, the coverage is "Secondary" for the spouse if they also have insurance with their own employer or "Primary" if they have no other coverage.

This paragraph is an assumption on my part, it does not come from the knowledge an insurance agent would have. I think the general rule one can assume for COB is that the "Primary" carrier will pay benefits based on the terms of the insurance policy. The secondary carrier will pay no more than the charges for the service(s) which were not paid by the "Primary" carrier, but depending on the terms of the "Secondary" carrier's policy, they may not pay the full amount unpaid by the "Primary" carrier.

In my state and city, for group health coverage for my family, we have received a paper copy of the current year's insurance policy in the first month we enrolled in the plan and in January of each year thereafter. The benefit sections of those documents describe how the plan pays for services provided by doctors who are not in the plan's network. There is also a section that describes how the plan coordinates benefits with other plans.

You should look at the Kaiser plan to see what provision it makes for out of network coverage. That would at least give you an idea if you can expect some money from Kaiser.

You can start by organizing your own records with
a) a list of all the bills you have had for your wife
b)use the EOB's (explanations of benefits) from the insurance company to see what they have paid
c) your own checkbook to see what you have paid.

You can ask the billing people at the doctor's offices if they will help you by submitting claims to Kaiser and then resubmitting claims to UHC after Kaiser has processed them.

If Kaiser pays nothing for out of network services, you will likely wind up being liable for part of the bills from the doctors.

 

[LostDollar]

I'm sure they are following the correct procedure, I'm just completely at a loss how I'm going to get out of this mess ... When I started adding my wife to my insurance plan I thought it would be a good thing but now I'm stuck in this crazy mess ...

Your bigger problems are twofold:
a) not knowing the legal meanings of primary and secondary for American health insurance
b)using doctors outside the network of your wife's plan.

For the past events, having the UHC coverage and possibly getting some payment from them as a secondary carrier may be the only money you can get towards your bills.

Having your wife on your plan might have worked better (depending on UHC's COB provisions) if your wife had gone to doctors within the Kaiser system.

 

[leevena]

since your not licensed or experienced in this business, why do u contribute? Kaiser is HMO with no OON

Your comment about Kaiser is not entirely true. They do have plans (PPO) that allow for use of non-KP providers as in-network.

 

[Yagents]

I deduced it from the original post that he's on a Kaiser "free" HMO, but good to know.

"All the doctors that my wife went to are not Kaiser doctors (Note here that for Kaiser you need to use specific Kaiser doctors and usually get referrals), but UHC network doctors - however UHC is asking us to submit all claims to Kaiser which Kaiser is going to reject since we didn't go through them."

 

[LostDollar]

I wish our benefits coordinator would have that info ... I'm trying to contact her and ask for advice navigating this issue but all she response is that I cannot make changes outside of enrollment periods which has nothing to do with what I'm asking help with ...

I am sorry for this post because it does not help you solve your problem, but in an American company the job of the "benefits coordinator" is to tell you what benefits the company provides you, the employee, and get your signature on the proper documents showing you accepted or declined the benefit. It is unlikely they will be of any help to you in solving your problem. (edit: at least that has been my experience in companies of 100-300 employees where I have worked.)