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When a HMO Won't Pay for a OON Emergency
- Thread starter Northeast Agent
- Start date
Trouble maker!
I did a double take on that username. Then I had to go back and see if that was in fact the chosen username. Very clever goillini.
- 29,492
Hahahaa, depending on what part of the world he's in, he might not even know what that is.
- Thread starter
- #44
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Good news! I just received an email from my client that she received a call from the carrier that she "owes nothing on the claim." She and her husband sent me a nice note to thank me.
This was after she had sent letters to Medicare, the state DOI, Dept of Aging, etc. We called Medicare together, who said because she was on a MAPD they could only see the claim on their end but not do anything else. The carrier said they couldn't pay due to the way the hospital coded it, and they came back saying the carrier considered her to have gone there for an "elective" procedure. Went back and forth with my contact at the carrier who advised me that it would probably get paid out, but needed to be shaken out first. I'm glad it worked out this quickly.
I'm sticking to what I said, though and no more MA seminars for me. I'm pushing Supps and will continue offering MA (without actively marketing them), but only to people I can sit down with individually and really explain the differences.
This was after she had sent letters to Medicare, the state DOI, Dept of Aging, etc. We called Medicare together, who said because she was on a MAPD they could only see the claim on their end but not do anything else. The carrier said they couldn't pay due to the way the hospital coded it, and they came back saying the carrier considered her to have gone there for an "elective" procedure. Went back and forth with my contact at the carrier who advised me that it would probably get paid out, but needed to be shaken out first. I'm glad it worked out this quickly.
I'm sticking to what I said, though and no more MA seminars for me. I'm pushing Supps and will continue offering MA (without actively marketing them), but only to people I can sit down with individually and really explain the differences.
Carriers will often pay claims extra-contractually just to avoid the stink. Not saying that is the case here, but I have been in the middle of some claims xs of $100k where the carrier opted to pay rather than be the lead story on the 6 o'clock news.
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