Need help with precert laws

Discussion in 'Health Insurance and Ancillary Benefits' started by Sam, Oct 25, 2006.

  1. Sam
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    Sam Founder Administrator

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    A client of mine just told me the following about her mother:

    She lives in New York and is a widow. She is 67. She has a Blue Cross PPO through her employer. (True group plan) She is the primary on the contract. She has a precertification requirement on her policy.
    She was recently hospitalized (In network) with some kind of inflammation on her brain. She was obviously in no position to call the insurance company to do a precert.

    Her daughter went with her, but had no idea about the requirements. At admissions, she asked if there was anything she needed to do and they said no. (I know, that makes no difference to the insurance company)

    Blue is denying all of her claims and has already rejected one of her appeals. They are telling her that she needs to pay everything, and also that she needs to appeal each and every specific claim, or she loses her right to appeal any of them.

    Any advice would be appreciated.
     
  2. somarco
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    somarco Guru

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    Not sure there are any laws per se on this. These things usually follow the language in the policy/contract.

    Pre-cert is used for non-emergency admissions. Emergency admissions usually are covered provided the carrier is notified in a reasonable amount of time following the admission . . . usually 48 - 72 hours.

    Without more details, it seems rather harsh of BX to do this.

    How much time elapsed between the admission and when the carrier was notified?
     
  3. insurebob
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    insurebob Expert

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    I suggest she get hold of an attorney (if she doesn't have one, she should get pre-paid legal) and have them contact the Evil Empire. Don't go it alone. Have an attorney to help.

    Any and all future correspondences should be in writing, and through an attorney. Even the Evil Empire hates bad publicity.
     
  4. James
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    James Guru

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    It seems strange to me that the Hospital didn't catch this? Yes advice them to retain a lawyer, a client should never attempt to take on Blue or any Ins. Company alone!
     
  5. Crabcake Johnny
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    Crabcake Johnny Guru

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    I fear we might not be getting the entire story. Pre-cert or pre-authorization only has to do with scheduled non-emergency events. Even if you don't obtain the authorization most plans limit the penality applied. For emergency events obviously no pre-authorization is needed.
     
  6. somarco
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    somarco Guru

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    That is not the provider responsibility. They have an obligation to treat in an emergency situation without regard to ability to pay.

    You are right, we don't have all the details. There are penalties for failing to notify in a timely basis, but I have never seen a total denial of the claim.

    Before hiring an attorney, there are independent claims adjudicators who will intervene for a nominal fee, usually in the $300 - $500 range.
     
  7. James
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    James Guru

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    Yea sure it isn't in an emergency situation but most providers being somewhat intelligent will assure to get a precert before providing services prior to an Non-Emergency treatment. It seems as though we are missing some key info here that I'll agree with, as this treatment wasn't consider an emergency. Even then if you are a provider such as a Hospital it would be prudent of you to know what is needed and a pre cert is basic of basics. Most Hospitals have entire departments doing nothing but pre certs, it just basic common sense if the hospital wants timely payment of services.
     
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