Question
What is the name of your state? FL
If an insurance company authorizes a hospital stay, are they obligated to pay their part? They paid and I received the Explanation of Benefits saying I owe $800. However, months later, I get a bill from hospital saying I owe $8,000 and am told the ins. co. took the money back as they were audited. The correct ins. company was notified and they will now pay a portion of the bill, but they only paid what they normally are contracted for. The hospital and 2nd insurance company aren't contracted with each other. I have insurance and yet I am being treated like I don't have it now by hospital because they won't honor rate 1st company quoted when the stay was authorized. If that insurance company had not authorized my stay, then I could have been transferred somewhere else and this all could have been avoided. I am not sure who is at fault here, but I did tell hospital twice that I had two kinds of insurance. Another problem is that the hospital nor the 1st insurance company will reveal to the 2nd insurance company what the rate was.
Answer
Please clarify.
Are you saying that a hospital stay was authorized by one insurance company, but your insurance company was changed and by the time the hospital stay occurred, you were covered by a different company?
I think that's what you're saying, but I want to be certain before progressing any further.
Answer
At the time I was hospitalized, I had two insurance companies. One authorized the stay, paid, and then realized they weren't supposed to pay on it. The other one was not even notified until the mixup was figured out. The authorization took place while I was at ER before being transferred to hospital where I was treated. I still have that insurance. I have not changed ins. companies. My employer has 2 different ones covering two different things, but I only have one insurance card.
Answer
Okay, now I'm totally confused. But I can tell you that insurance company #2 is not bound by an authorization issued by #1.
Answer
I understand that ins. co #2 is not bound by what the first company authorized. However, they were going to work with that ins. company and the hospital to zero my balance and yet noone would tell them what the rate was so they just paid what they pay at other hospitals. In fact, they said they paid more than normal. I still have a $5,000 balance, however. I should only have to pay $200 according to the second insurance co. or $800 according to the first ins company.
I am sorry I have confused you, but I really need to know if once an insurance company authorizes something, are they responsible in any way? If they hadn't authorized it, all of this could have been avoided. To be honest, I am confused too and frustrated. I plan to call the first ins. comp. and hospital again, but need to know what approach to take. Recently, I have just been dealing with the 2nd ins. co. and the mgr. there has gone as far as she can go including sending a letter to the hospital from the ceo of the ins. company. She told me she can not get 1st ins. co to return phone calls.
Please if you still don't understand this, please ask me.
Answer
Why don't you start by explaining to me the two coverages. What kind of coverage is insurer #1? What kind of coverage is insurer #2? Are both provided by your employer? If not, which one does your employer provide and where does the other one come from? Which is the primary carrier?
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I was hoping to not have to go into specifics. Anyway, both insurances are provided by my employer. The insurance company who authorized the stay was my medical insurance and the other one is mental health insurance. I went to ER because I could not keep anything down including my meds for bipolar disorder. I was transferred to psych. hospital and was there for four days and was refused any medical treatment. (different issue entirely) When I got out, I had my gall bladder taken out within two days. (this was the problem the whole time) At the ER, I told them I had two insurance companies and thought everything was taken care of. I was very sick and in pain and had no idea the insurance that authorized the stay did it incorrectly until months later. They actually still have not notified me that they took money back, etc. I found this out from the hospital.
My question still: Is the medical insurance by authorizing this stay at fault in anyway? If they had done their job correctly, I would have been transferred to a psych hospital where things could have been authorized and contracted correctly.
Thank you for your time in answering my question.
Answer
In all my years in this industry, I can honestly say I have never run across a separate plan for mental health. There are supplemental hospital indemnity plans, cancer plans, heart & stroke plans and quite a few more that I won't take the time to mention.
Many states have enacted mental health parity rules that govern employer sponsored health plans and some individual health plans as well.
The plans you have described are truly unique, even for FL. Now you have my curiousity piqued.
Are you referring to a true, employer provided group major medical plan and an employer provided group mental health plan? Or are one (or more) of these plans individual coverage?
I am aware of at least one carrier in the individual market that offers what they term major medical (although that term could certainly be challenged) that has little or no mental health benefits. Of course they also offer a host of riders and other supplemental policies to augment the deficits in their primary plan.
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Yes, both plans are truly provided by my employer. Neither one is an individual plan.
Since this is a unique plan, does that mean my situation is unique, too? If so, how will I get to the bottom of this?
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Elizabeth, an insurance carrier (or anyone else) can only go by the information they have available to them at the time. I'm afraid that without reading the policies in their entirety, there's really no way for anyone here to answer your questions. We'd have to know the terms of the policy; how the two coordinate; what the regulations for authorizations are; and so on.
From your first post or two I hoped that it would turn out to be a simple administrative error that I could assist you with, but I'm afraid that's not the case.
A couple of suggestions; there must be someone in your HR office who works with your benefits. If you trust them to keep your information confidential (and the law does require them to do so in this instance) you can see if they can help you. Many times (I know by experience on both sides of the desk) HR has access to people higher up in the insurance organization than you would be able to access on your own.
If you absolutely can't bring yourself to let anyone in HR know about your situation, ask them for the name and phone number of their insurance broker. I assure you that no reputable broker would give your info to the employer (they, too, are required to keep your information confidential) and they too have access to high-level contacts at the insurance carrier.
You might even want to consider showing your insurance plan to an insurance attorney and see if he can offer any guidance.
Good luck.