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rated:
Hello everyone. Need your help and/or advice with medical collections and filing a complaint against the health insurance provider with the appropriate government agency.

We live in Louisiana. Son has been receiving daily services for autism (high functioning) from same service provider organization for several years.
Same health insurance provider since 2012
07/12 - 08/14 via employer
09/14 - 11/15 via COBRA
12/15 - present via employer
Large service provider, Tier 1, in-network. Insurance has been approving services with periodic 6-month authorizations

3 issues
1) Insurance incorrectly applied 2015 claims to out-of-network, hence showing $6500 OOP-Max (for out-of-network) instead of $2600 OOP-Max for in-network
2) Insurance denied claims for 11/03/15 - 12/31/15 service dates stating no coverage during that period
3) Service provider also said 2016 claims were being withheld as authorizations were done during period insurance claimed no coverage.

Have called insurance several times, taken down details, issues still not fixed. No answer as to why insurance shows cancelled in their records for that period.
Have called COBRA administrator multiple times, including 3-way call with insurance. COBRA administrator confirmed multiply that insurance was continuous per their records, was never cancelled at their end and premiums received timely. They also said even if they had cancelled they would cancel end-of-month and not during the month.
Asked COBRA administrator to send us detailed invoice(s) showing covered persons, premium payment dates, amounts. Confirmed twice over phone but no documentation ever recd.

Have always kept provider in the loop, via phone, emails, including sending complete details of
1) all interactions with insurance, COBRA administrator
2) online receipts of premium payments
3) premium payment withdrawals from bank account

Provider asked 10/05/16 to make token good faith payment to continue services and avoid collections. Paid off $4000 towards 2015, 2016 contractual deductibles, OOP-Max, as good faith, despite never having received 2016 invoices from provider. Despite all this, provider insisted on payment plan. Did not accept as both legally and on principle, insurance owes the balances.
Provider stopped services completely despite paying off our portion of balances in full and as good faith payments and further, sent to collections.

Responded to Collection Agency disputing validity. On 12/10/16 received Collection Agency letter dated 12/02/16 with supporting docs from provider - claim denials from insurance and payment agreement with service provider. Per Collection Agency, collection account now open again.

We always timely pay our bills. Additionally, we will be out of country beginning 12/20/16 for 3 weeks.

What do we (need to) do at this stage?
Contact Louisiana Attorney General (do not handle insurance)? Department of Insurance (unsure if health insurance companies are covered)? Any other state or Federal Agency?
What should we respond to the Collection Agency, how and by when?

Truly appreciate all the help/feedback. Thanks a lot!

TL; DR: Insurance company erroneously processed/denied claims and have not fixed issues despite multiple interventions. Provider sent to collections, disputed, account reopened. How to handle Collections Agency, Health Insurance provider?

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rated:
Regardless of whether the insurance pays, your provider is entitled to be paid for the services rendered. The problem between you and your insurance carrier is your problem, not your provider's.

rated:
The Department of Labor would be a good place to start, particularly since COBRA is involved. The state insurance commission probably doesn't have any enforcement power here, but may be able to help.

rated:
Thanks for the replies and helpful info.

Just to clarify, we absolutely agree the provider needs to get paid. However, this is a huge, long-term provider and the claim amounts in question are <5% of the services billed for in the last 4 years (6 hours daily services for last. 4 years).

Need the provider/collection agency to bear with us just a little until the issue is resolved, clearly an error on the part of the health insurance provider. And at least on an urgent basis till we get back in the country. How do we go about it?

Looking at the LA websites, it seems the Department of Insurance seems to be applicable to general insurance companies. Who regulates health insurance providers?

Thanks

rated:
I only skimmed your post, so I don't have a complete handle on your situation, but I don't think that you said anywhere that you have filed a formal "appeal".

(If you had filed a formal appeal, I think that you would probably already know the information you are asking here regarding who in LA would handle this, etc., so I expect that you have not.)

As far as I know (and I admit that my knowledge is limited, so do your own research), every 'typical' health insurance policy has a formal appeals process that is spelled out in the contract. I can't imagine that COBRA plans don't allow for formal appeals, also.

In my policy's contract, there are 3 levels of appeal, the first two are with the insurance company internally and the final one is with my state's insurance regulator. Previously, I have had to make formal appeals at the 1st and 2nd levels (and I won them). I never had to go to the third level and appeal to the state insurance commissioner, but I would have been prepared to do so.

My health insurance company's telephone agents made it *seem* like my simply talking to them and providing them information (which it sounds like you have done with your company, repeatedly) was pretty much the same kind of thing as making a formal appeal: BUT NO, IT IS NOT THE SAME THING. They even referred to it as my "appeal", but it was not an appeal that they took seriously, because it was informal. Therefore, you must read your policy's small print and follow the formal appeal instructions exactly. It wasn't until I submitted my formal appeals that it seemed like my concerns were taken seriously; even then, months and months went by before I got decisions from them.

As far as I know, once you have submitted a formal appeal, you can let the providers and the collections agencies know this, and ask for some extra time while the appeal is being processed. I was given a couple of months extra by my providers when I informed them of my appeals, but I put all that into motion immediately after my claims were denied -- it was within the same calendar year, within the same insurance plan, etc.
(I do not know what would happen in your case, as it sounds like your situation has been dragging on for over a year, and across several insurance plans, so maybe you would not get any more leeway.)

---
If, however, you have already filed formal appeals, up to the highest level, and these were rejected,
yet you have had no involvement with the LA Dept. of Insurance or the LA Consumer Ombudsman (whatever it's called there), then yes, of course, you should contact them by phone immediately and ask them if there is anything else you can do. It won't hurt to call them and see if they can help you.

---
Let us know how it works out.

rated:
No wonder health insurance is so expensive.

Bring on the red.

rated:
From what I understand with the latest changes in Credit, anytime a medical issue is resolved/paid it will immediately be removed from your credit. With that said, assuming you will resolve or pay this eventually, I would tell them to go pound sand. I'm not paying until insurance resolves the issue. Want to get paid? Then how about YOU (the provider/hospital) spend some time making calls to the insurance to help resolve the issues instead of just calling to complain. No normal person knows the lingo, codes, requirements, or paperwork that goes into a typical insurance claim. So if they want to get paid, they should be offering to setup calls with the insurance company if they want to get paid. i would be glad to tag along and help.

To be honest, (I'll probably get neg'd for this) I would tell the hospital to pound sand for the time being. Dealing with insurance companies is something that they legally accepted by accepting your insurance for their service, so no - I don't buy into this whole BS narrative of the provider needs to be paid for their service immediately. By accepting the insurance and their practices, they should be bound to their period of time for resolving claims. If it takes 6 months to resolve, so be it. Don't like it? Don't accept the insurance.

That said, it looks like Oppidum has the best advice for appealing.

rated:
oppidum, justignoredem, thanks for the replies.

We have not filed any formal appeal ourselves. The provider had, on our behalf but it was rejected stating no coverage.

In this case, the coverage seems erroneously cancelled by the insurance despite the COBRA admin showing coverage always current and continuous. Even the 1095-C forms showing Employer Provided Coverage, provided by the insurance company, shows coverage for November, December '15. Hence have believed this is not a "normal" issue that was subject to the appeal process but more of a disconnect/processing issue between various departments of the insurance company.

Similar to the 30 day response period for disputing a credit collection letter, is there a specific period by which we would need to respond to them now? Also, not sure if writing to them about the facts/details of the situation and asking them to wait some more until issues are resolved is appropriate and/or would help. What would you folks suggest responding with? Thanks a lot in advance.

rated:
Since this matter is so important and so costly, if I were you, I would not leave the appeal in the provider's hands, and I would see if I could file an appeal on behalf of myself and my family.
Even if the first level of appeal was rejected, which can often happen and which is not the final word on the matter, there are further levels of appeal, and pursuing an appeal beyond the first hurdle is a routine situation for insurance customers. 
After a year of trying to talk to them about it and getting nowhere, a formal appeal is an appropriate way for the customer to remedy a "disconnect" between various departments of a health insurance company, if that situation resulted in many expensive claims being denied.
 
After getting formal internal rejections at every level of formal appeal from the insurance company -- and maybe you are at that point already -- then the appeal goes to the regulator or arbitrator. 
If you did all the right things, you had continuous coverage, and you have proof of that, but the insurance company is insisting that you did not, it sounds like you may need to have an external authority step in.
The fine print at the end of your insurance contracts should surely give you information about the state-level official department (insurance commissioner or whatever it is called in LA) that you can turn to after you have exhausted all other alternatives.
(If your contracts don't state the name of the official government agency/arbitrator that you can ask for help, just start calling likely government departments to ask for guidance, because it seems that your credit is in imminent danger of being harmed.)

Actually, at this late stage, since your son gets *daily* treatments and his claims from all of 2016 were not honored, it sounds like a lot of money is at stake and you may want to give up trying to solve it on your own, and immediately consult a lawyer or another paid professional to help you with this.

rated:
justignoredem said:   From what I understand with the latest changes in Credit, anytime a medical issue is resolved/paid it will immediately be removed from your credit. With that said, assuming you will resolve or pay this eventually, I would tell them to go pound sand. I'm not paying until insurance resolves the issue. Want to get paid? Then how about YOU (the provider/hospital) spend some time making calls to the insurance to help resolve the issues instead of just calling to complain. No normal person knows the lingo, codes, requirements, or paperwork that goes into a typical insurance claim. So if they want to get paid, they should be offering to setup calls with the insurance company if they want to get paid. i would be glad to tag along and help.
  This doesn't sound like a question of "the insurance company says they won't cover XYZ service/procedure, but they should, so the service provider should help."  Rather, it sounds like the insurance company is saying that the OP simply doesn't have coverage from them during the time period in question. I'm not clear how the service provider could help with an issue like that. 

rated:
cestmoi123 said:   This doesn't sound like a question of "the insurance company says they won't cover XYZ service/procedure, but they should, so the service provider should help."  Rather, it sounds like the insurance company is saying that the OP simply doesn't have coverage from them during the time period in question.
Yeah, it is not like the Provider can tell the insurance, "No, you are wrong. Our customer did have COBRA/Insurance during that time period."

OP,
You gotta fix this with COBRA admin. The Provider cannot do that.

rated:
fwhelp said:   and filing a complaint against the health insurance provider with the appropriate government agency.
...
but more of a disconnect/processing issue between various departments of the insurance company.
And you blame the provider for that ?

rated:
fwhelp said:   Asked COBRA administrator to send us detailed invoice(s) showing covered persons, premium payment dates, amounts. Confirmed twice over phone but no documentation ever recd.And you stopped calling after 2 times ?

rated:
xoneinax said:   
fwhelp said:   and filing a complaint against the health insurance provider with the appropriate government agency.
...
but more of a disconnect/processing issue between various departments of the insurance company.

And you blame the provider for that ?

The OP wrote "health insurance provider", meaning the health insurance company, not the provider of medical care (doctor, clinic, autism specialist, etc.) 

The health insurance provider/company would be to blame for mistakes made by its departments.

rated:
xoneinax said:   
fwhelp said:   Asked COBRA administrator to send us detailed invoice(s) showing covered persons, premium payment dates, amounts. Confirmed twice over phone but no documentation ever recd.
And you stopped calling after 2 times ?

With this kind of thing, the customer has to be SO insistent and follow things through to the bitter end. 
You can't go 90% of the way and then think that surely they will handle the other 10%... no, they probably won't. 
You will probably have to mostly fulfill their role in the matter too, in order to get the result that you want. 
It may not be fair, but you are the only one who is looking out for your interests.

rated:
wilesmt said:   No wonder health insurance is so expensive.

Bring on the red.

  If you mean all the wasted time, money, energy, and salaries for the bloated bureaucracy that is the medical insurance industry, I wholeheartedly agree. But, I doubt that's what you meant. 

rated:
We are going through a similar process in our state.  No level of appeals through the insurance company has done any good.

You should file a complaint with your state's Department of Insurance/Insurance Commission.  If the employer(s) is/are self insured, you will be referred to the Department of Labor (ERISA), otherwise the state should handle the complaint.

rated:
OP,

Haven't read through everything you wrote in detail, but bottom line, you won't get a simple answer on the internet. Every cluster**** is unique.

You need to take a step back and organize your thoughts on this.

Medical Provider:
Responsible for documenting treatment plan and case notes. Responsible for assisting with Insurance Medical Review. Responsible for timely submission of accurate medical claims (to the correct insurance, with correct icd/cpt codes, with correct subscriber info).
Not Responsible for dealing with insurance denials, especially denials based on coverage.

Insurance Provider:
Responsible for timely responses to correctly submitted claims and appeals. Responsible for providing accurate Explanation of Benefits, Medical Necessity Determination letters, and documented denials of coverage.
Unfortunately, not responsible for responding to improperly filed claims/appeals.

Patient (or Ins Member/Subscriber):
Responsible for reviewing claims for accuracy. Responsible for filing timely appeals.

State Dept of Insurance Regulation:
Responsible for ensuring that Insurance Providers follow the law. Laws vary by state.
Generally good for following up with Insurance Providers that don't meet timeliness requirements and written notification requirements.
Generally not good for addressing improper denial reasons, especially denials for medical necessity.

=========
Not an exhaustive list of responsibilities and some things vary by state, but generally focus your inquiries on the responsibility that someone failed to meet. Know your state's timeliness requirements and focus your complaints on failure to meet those (I have seen claims paid that should have been denied because an Insurance Provider failed to respond in time)

Make an exhaustive list of dates/actions including dates of service with icd/cpt codes.
Get copies of everything including treatment plans, case notes, doctor referrals, evaluation reports
Document date/actions of all communications including phone calls/faxes/letters

If you are going to complain to someone or about someone, keep the complaint concise and only include the facts relevant to the complaint.

For example, for the medical provider, focus your complaints on
requests for documentation that they failed to provide
claims they failed to file accurately (wrong ins info? wrong icd codes?...)

For the ins provider, focus your complaints on timeliness requirements
failure to respond to a claim (30 days??)
failure to respond to a medical necessity review they requested (45 days?)
failure to notify their intentions or request more time (15 days?)
failure to provide a proper letter of denial
failure to respond to a properly filed appeal (to the correct address)

This is just a starting point.

Seeing 6 hours per day probably raised the bar for medical necessity approval. If justified, the level of review/documentation would be pretty high compared to most reviews. Then, even if medically justified, most plans still wouldn't cover that level of service. You need to read your summary plan description very carefully to make sure you are fighting for something that is covered (not the 6 page document, the 200+ page document your insurance provider is required to provide upon request).

I'm not an expert and I do not guarantee the accuracy of everything I said. I just have experience with medical claims and insurance companies. I highly recommend getting involved with a support group to connect with others that have experience dealing with this.

rated:

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