Question
In florida, divorced dad NCP w/ eight year old. Divorce agreement says I am responsible for all insurance and medical costs and I carry a comprehensive plan for my daughter with UHC. My daughter happens to be a model/actress and I was unaware she was eligible for coverage with the screen actors guild. My ex presented the SAG card to the pediatrician's
office, they filed with them first and now I have been trying for months to get UHC to reverse its refusal to pay
based on alternate plan being available. Coordination of benefits people are taking their sweet time with the problem, I'm out of pocket for a few hundred bucks meantime. Pediatricians office has backlogged claims that I demanded they hold off until some understanding was reached as I want to have UHC the primary provider, they
pay better benefits. Pediatricians office refuses to file both, they will only file primary. I tried to remove my
daughter from the SAG plan but that is impossible to do.
As I am responsible party why can't I insist that the doctor
use my insurance as the primary and let me file with SAG
after? This is taking way too much of my time.
Answer
This is a recurring problem, and the Coordination of Benefits provisions are hairy. It really depends on the policy language as to who is primary and who is secondary. The good news is that eventually you should not have anby out of pocket.
As to the doctor's office's filling out the forms twice, you'd want to arrange with the secondary policy if they'd take a copy of the bill or submission. Face it, doctors hate the plans as they cut the doctors' fees and benefits and take their staffs lots of time to fill out, time that no one pays for.
Answer
Check with your human resources or your policy to see how coordination of benefits is structured, as it'll be based on a particular "rule". For instance, some plans go by what they call a "birthday rule," meaning whose ever birthday comes first between you and the other insurance holder, is considered primary. This is based only on the month and day, and not the year.
Deciding which insurance is primary is not an arbitrary thing, and is determined between the two insurance companies that are coordinating benefits, and can be according to one of several possible "rules" like the example above.
If the doctor providing medical services to your daughter is contracted with one or the other insurance companies, then s/he's agreed to accept a contracted amount as payment for services and your daughter's not responsible for the difference, aside from any deductible (if any) and copay amounts that apply. There's several instances when the residual amount due remaining after payment by the primary insurance, may be higher:
1)your daughter's primary coverage carries a high coinsurance amount, or
2)her plan allows her to go "out-of-network" and she does - this means she can see doctors that aren't contracted by her primary insurance, but are paid at a lower benefit rate (usually around 70 or 80% of what is considered "reasonable and customary") with the remainder being patient responsibility.
If neither is the case, then it's possible her other coverage has paid the network rate (or contracted amount agreed to by the doctor if he's contracted or "in-network"), less any copay or deductible that applies.
The secondary, then, comes in and will pay according to one of several methods, depending on what your employer purchased for his employee coverage. Some will pay up to the allowable amount of the primary coverage, while others will pay up their own allowable amount (as the secondary).
This can calculate out at a lower or higher secondary coverage amount, depending on which company has the better deal, and which one is applied.
What's really bad is that the staff with your daughter's doctor are, evidently, too lazy to do their job and are expecting you to do the footwork so they can get the money. If this is the case, then they need to provide you the proper tools for doing so. Rather than simply sending you a bill with what's been paid and what they're alleging to be due, they need to send you a copy of the other insurance's explanation of benefits (or EOB). Without it, your insurance has nothing to coordinate benefits with (ex: what is the primary insurance's allowable amount, for instance, or what amounts have they deemed "not covered", and finally, what amount does the primary insurance consider "coinsurance" or the amount that "patient pays").
If her doctor's staff is just sending you rudimentary bills, call them up and tell them to do a complete accounting, if need be, and provide you with copies of all outstanding EOBs. Keep copies of these for yourself, as well, in case you need them in the future.
Then send these to your insurance company with a cover letter (keep a copy of that, too) and explain that you're resubmitting information that they've requested for coordinating benefits on your daughter's claims. This will help to avoid mix-ups and denials as being "duplicate" or already-processed claims, and issues like timely filing. Your submission of these claims should be based on your first response, even if it wasn't right (because the doctor's staff didn't send what you needed to do their stinkin' job!).
And if this hasn't confused you to the point of screaming and ripping out your hair, if your insurance is being unreasonably slow about proper processing of your claims even after you've given them the proper information they need to do so, you may be able to get action by contacting the Dept. of Insurance in your state.
This might be the case if you've made every possible effort to gain resolution, such as making sure you've sent the right information they need (other insurance's EOBs), making phone calls to your member services or customer advocate, or writing them a letter. If clams were denied for reasons you disagree with, there is option to appeal. Your benefit handbook should explain how. Another avenue, is to contact your human resources and let them know your problems with their coverage. They, many times, have more direct access to someone in cases such as this, to get you some results. Or, if human resources is not readily accessible (as it seems they're NOT with many companies), talk to your supervisor or someone in management and see if they'll pull some strings.
If the staff with your daughter's doctor are acting upset about balances they think are too overdue, you might suggest they do what staff at other doctor's offices do all across the United States - provide a service for their customers that they're more equipped to do, and (*gasp!*) quit expecting their customers to do their work for them. Especially if, as in your case, they want to complain about it, later. If they've not known enough to even send you the correct information you need, then perhaps it's no wonder they're so anxious to dump these responsibilities on you!
Keep on it until you get results and, chances are, you won't have to deal with this again. You know what they say about the "squeaky wheel" - don't give up - keep hounding and pounding until they hear your "wake-up" call.