When a HMO Won't Pay for a OON Emergency

Thanks, all. I'll take Somarco's advice and get into the weeds regarding diagnosis and treatment codes with the billing provider(s) and carrier before proceeding with CMS.

Good.

And stop believing customer service reps. They are getting paid to read to you from a computer screen. I'm sure they are giving the info they have, but just call and tell them you want a supervisor. Tell them you want the claim reviewed and ask for the appeal process, "just in case" you need it after this call.

Never, ever take a no from a front line person.
 
Lee, your point is not totally lost in this discussion.

Todd asked about how long she was in the hospital (24 hours?). The rule keeps changing for Medicare patients, but until recently a hospital could admit you for observation for "several days". The impact on how Medicare pays, and more importantly, what it doesn't pay for if discharged to an ECF is considerable.
 
Well, here's the latest. Customer service called the client earlier in the week and said to hold off on paying anything. Claimed they didn't realize there was an authorization number. Yesterday the client emailed me, there are MORE bills arriving to the tune of close to $60,000 in total! Then in the late afternoon the husband called and said customer service just called... And they aren't paying as your wife was "under observation." Oh, and the authorization # wasn't valid.

I emailed my upline this morning as he has been strangely silent. Told him he needs to call me on Monday to help me with the appeal process. I am also no longer doing any seminars for said carrier and the only HMOs I will offer (if I do at all) will be the ones who have the extended networks. I hate how during seminars we don't talk about "admitted, vs "under observation, and also the "three midnight rule."
 
Well, here's the latest. Customer service called the client earlier in the week and said to hold off on paying anything. Claimed they didn't realize there was an authorization number. Yesterday the client emailed me, there are MORE bills arriving to the tune of close to $60,000 in total! Then in the late afternoon the husband called and said customer service just called... And they aren't paying as your wife was "under observation." Oh, and the authorization # wasn't valid.

I emailed my upline this morning as he has been strangely silent. Told him he needs to call me on Monday to help me with the appeal process. I am also no longer doing any seminars for said carrier and the only HMOs I will offer (if I do at all) will be the ones who have the extended networks. I hate how during seminars we don't talk about "admitted, vs "under observation, and also the "three midnight rule."

This is crap. File the appeal with Medicare.

Tell your client the next time she talks to them to say "Well. Ok. I'll let my friends know, so they know how to give a 1 star rating since you are refusing to help an old lady who had to go to the emergency room"

And no, I'm not kidding.
 
This is crap. File the appeal with Medicare.

Tell your client the next time she talks to them to say "Well. Ok. I'll let my friends know, so they know how to give a 1 star rating since you are refusing to help an old lady who had to go to the emergency room"

And no, I'm not kidding.

Exactly how does a person give a 1 star rating? It's not like going out to Medicare.gov and writing a product review.

And as previous commenters have stated, going straight to Medicare is going nuclear pretty fast. You know what they do with the complaints? Send them straight to the plan to review. You think they have special access to what was submitted and know the plan's ins-and-outs? Just start the appeal through the plan.
 
Individuals do not assign star ratings to PDP or MA plans. Medicare does.

Getting Medicare involved at this point may or may not be the right way to go. The difference is when Medicare notifies a carrier of a complaint the carrier usually responds differently vs. when a consumer makes the complaint.

My issue with bringing in Medicare is questioning whether that kind of escalation is necessary. But everyone handles things differently.
 
do insurance agents get a different quality of support from a carrier than a consumer does?
 
do insurance agents get a d.ifferent quality of support from a carrier than a consumer does?

Yes and No. Agents should know how to navigate the system better and therefore get better results than a consumer. Agents don't get better treatment because they are agents. My doc's nurse told me UHC always denies a certain surgery. After I got mine pre-authorized, she was able to get the next one through herself.

Individuals do not assign star ratings to PDP or MA plans. Medicare does.

Right, but Medicare bases those Star ratings on consumer complaints, among other factors. A call to Medicare gets a pretty quick response from the insurer to the consumer member.
 
Exactly how does a person give a 1 star rating? It's not like going out to Medicare.gov and writing a product review.

And as previous commenters have stated, going straight to Medicare is going nuclear pretty fast. You know what they do with the complaints? Send them straight to the plan to review. You think they have special access to what was submitted and know the plan's ins-and-outs? Just start the appeal through the plan.

Do you work for a carrier? Or have you ever in the past? I have and your answer sounds like you work for one now.

Complaints from enrollees are handled on a completely different level than complaints submitted by CMS or a DOI.

Agent has called. Client has called. What do you expect them to do? Rollover?

Its NOT nuclear. Its the process in place. The carrier has chosen to pay the claim incorrectly. The client is getting billed and those bills have now surpassed $60K.

And star ratings include member surveys. All (I think? At least I know they appear at my parents and grandparents annually) MAPD and PDP enrollees are sent a survey. https://www.medicare.gov/find-a-pla...x?measureId=75&SourcePage=details&scoreType=2

Would you let the carrier do this to your mother?

Treat every client the way you want your mother treated.

LD-Sometimes. Depends on several factors, including number of policies. "Are you a shark or a minnow?"
 
Yes and No. Agents should know how to navigate the system better and therefore get better results than a consumer. Agents don't get better treatment because they are agents. My doc's nurse told me UHC always denies a certain surgery. After I got mine pre-authorized, she was able to get the next one through herself.

Thank you for the answer. I have no wish to involve you in old disputes of mine but the exchange below is why I asked.

An agent response to a post of mine implied, that in fact, agents do receive different treatment from carriers which I am not in a position to appreciate.

In the current thread I am trying to arrive at my own evaluation of the right blend of moderation and force being urged by two posters and that previous thread experience was giving me difficulties with the validity of my own judgements.

Originally Posted by LostDollar
I wouldn't count on anything involving [**co A*****] dealing with folks outside their organization being an improvement over previous activities. In regard to GHP customer service, the transition from [**co B bought out ***] to [*** co A that purchased it***] caused a dramatic decline in effectiveness.

response by an agent
You obviously haven't dealt with any of these companies from an agent's perspective. And since this forum is mostly agents sharing their thoughts, that is the viewpoint in which I posted that comment last year.

----------

LD-Sometimes. Depends on several factors, including number of policies. "Are you a shark or a minnow?"

If i'm in the same tank with you and I've p***ed you off, I'm over hiding in the weeds!
:D
 
Back
Top