VSG to DS: Untimely Filing - ARE YOU KIDDING ME????

[Larra]

Good idea, and you can email it to us if you don't want to publish it here.

 

[Spiky Bugger]

I think it's worth a shot, but truth is, I don't know the answer. Diana may be more helpful.

I had an MRI of something in 2016. Facility billed my secondary insurance, but not Medicare, my primary. When the facility figured it out--secondary kept denying because...you know...they were secondary--and finally billed Medicare over 365 days post-service, Medicare denied the claim for lack of timely filing and advised me not to pay.

That's what made me ask.

 

[DianaCox]

I'd trust Spiky on such issues.

 

[Stefanie S.]

I had an MRI of something in 2016. Facility billed my secondary insurance, but not Medicare, my primary. When the facility figured it out--secondary kept denying because...you know...they were secondary--and finally billed Medicare over 365 days post-service, Medicare denied the claim for lack of timely filing and advised me not to pay.

That's what made me ask.

Interesting! So the provider couldn't make you pay? The trouble with me is that I had to pre-pay the day before my surgery. They have my money and are not interested in giving it back. I have sent letters to the clinic, the billing office, and even the surgeon! They just keep saying... "well, the reason is because it was initially denied." It's like a broken record. They infuriate me.

OHHHHHHHHH.... on another note... I've noticed that the claim has charged me for a gastrectomy too. I was a revision and my stomach was not touched! I'm tempted to get a lawyer if I could be guaranteed to win as I otherwise couldn't afford it.

 

[Stefanie S.]

Nah, I'm not private. I'd love for this experience to help someone, so public it is! Timeline... Surgery was January 24. Insurance denial overturned on June 28. Claim filed some time end of July.

August, September, October - Weekly hell dealing with BCBS and Duke Billing.

 

[Spiky Bugger]

Interesting! So the provider couldn't make you pay? The trouble with me is that I had to pre-pay the day before my surgery. They have my money and are not interested in giving it back. I have sent letters to the clinic, the billing office, and even the surgeon! They just keep saying... "well, the reason is because it was initially denied." It's like a broken record. They infuriate me.

OHHHHHHHHH.... on another note... I've noticed that the claim has charged me for a gastrectomy too. I was a revision and my stomach was not touched! I'm tempted to get a lawyer if I could be guaranteed to win as I otherwise couldn't afford it.

Sooo...you had to pay as a cash patient but if they honor the insurance payment it would be for the "lower, negotiated rate" they tout? Ergo, their one-day-too-late performance saved them money?

 

[DianaCox]

Wait a minute - the six month clock should have started ticking on June 28th. You (or the hospital billing system) could not submit a claim before then.

Bad faith denial of an insurance claim can involve punitive damages. I would go talk to an insurance lawyer ASAP. Simultaneously, call the state insurance commission.

I'm not recommending any of these firms, but suggesting you read their self-promoting materials for informational purposes:
http://www.maynardharris.com/Insurance-Disputes/Bad-Faith-Insurance-Denial.shtml
http://www.brentadams.com/library/what-is-north-carolina-insurance-bad-faith.cfm
https://www.surranoinsurancebadfaith.com/bad-faith-by-insurers/insurer-bad-faith-in-north-carolina/

 

[Stefanie S.]

Sooo...you had to pay as a cash patient but if they honor the insurance payment it would be for the "lower, negotiated rate" they tout? Ergo, their one-day-too-late performance saved them money?

Precisely

 

[Stefanie S.]

Wait a minute - the six month clock should have started ticking on June 28th. You (or the hospital billing system) could not submit a claim before then.

Bad faith denial of an insurance claim can involve punitive damages. I would go talk to an insurance lawyer ASAP. Simultaneously, call the state insurance commission.

I'm not recommending any of these firms, but suggesting you read their self-promoting materials for informational purposes:
http://www.maynardharris.com/Insurance-Disputes/Bad-Faith-Insurance-Denial.shtml
http://www.brentadams.com/library/what-is-north-carolina-insurance-bad-faith.cfm
https://www.surranoinsurancebadfaith.com/bad-faith-by-insurers/insurer-bad-faith-in-north-carolina/

Thank you Diana! I had no idea this was out there. Insurance companies enter the contract with me promising to be reasonable and fair! I love that line - I would say that filing a claim 2 days late is not a reasonable reason to deny payment. AND like you said, especially since I wasn't even approved until June 28. Thank you so much for taking the time to send me these links - SPECIFIC to my state even. You rock!

 

[southernlady]

Stefanie, do you live in NC or just travel to Sudan cause he was closest? If you live in NC, the NC Insurance Commission is where you need to go to protest. http://www.ncdoi.com/ (I know it's a dot com but it is listed as the proper page from NC.gov
https://www.ncmedboard.org/resource...-resources/complaint-process/file-a-complaint
https://corporate.dukehealth.org/chancellors-leadership-team Mr. Kenneth Morris (CFO) and Ms. MaryAnn Black (Community Relations)
https://www.dukehealth.org/contact-us/compliments-suggestions-and-complaints
https://www2.ncdhhs.gov/dhsr/ciu/filecomplaint.html

Long story but the upshot is try to find the phone number of the upper people (CEO, CFO) and call direct. But also file a complaint against Duke Health for untimely submission of the bill.

I had an issue with the University of Missouri hospital system billing me (in 2001) for what was not paid by the insurance in 1999, early 2000. NOT legal but I had to fight. Original bill was over $800 and they count on people being scared and just pay. I got pissed and thanks to being anal about keeping EOB's, I found all but $8.00 worth. But the lower level staff was giving me the run around. So I found the CFO's phone number. I called it and damned if he didn't answer his own phone. I was polite but laid out my case, stating I had all but one EOB proving I did not owe anything according to the Insurance company that paid them. I admitted I didn't have one of them but that amount was only $8.00 not $800.00. I got off the phone with him and less than 10 mins later the division head of the dept called me stating she had found my EOB's and agreed all I owed was EIGHT damned dollars! We did pay that.

I found out later, the CFO's phone number was deleted and it just went to the main office.

 

[Stefanie S.]

Stefanie, do you live in NC or just travel to Sudan cause he was closest? If you live in NC, the NC Insurance Commission is where you need to go to protest. http://www.ncdoi.com/ (I know it's a dot com but it is listed as the proper page from NC.gov
https://www.ncmedboard.org/resource...-resources/complaint-process/file-a-complaint
https://corporate.dukehealth.org/chancellors-leadership-team Mr. Kenneth Morris (CFO) and Ms. MaryAnn Black (Community Relations)
https://www.dukehealth.org/contact-us/compliments-suggestions-and-complaints
https://www2.ncdhhs.gov/dhsr/ciu/filecomplaint.html

Long story but the upshot is try to find the phone number of the upper people (CEO, CFO) and call direct. But also file a complaint against Duke Health for untimely submission of the bill.

I had an issue with the University of Missouri hospital system billing me (in 2001) for what was not paid by the insurance in 1999, early 2000. NOT legal but I had to fight. Original bill was over $800 and they count on people being scared and just pay. I got pissed and thanks to being anal about keeping EOB's, I found all but $8.00 worth. But the lower level staff was giving me the run around. So I found the CFO's phone number. I called it and damned if he didn't answer his own phone. I was polite but laid out my case, stating I had all but one EOB proving I did not owe anything according to the Insurance company that paid them. I admitted I didn't have one of them but that amount was only $8.00 not $800.00. I got off the phone with him and less than 10 mins later the division head of the dept called me stating she had found my EOB's and agreed all I owed was EIGHT damned dollars! We did pay that.

I found out later, the CFO's phone number was deleted and it just went to the main office.

Smart thinking for you to contact the CFO! Thank you for the links. This is great. You know, BCBS and Duke kept telling me I had to go back through the appeal process, which I have started, but that took 5 months last time. The NC Insurance Commission's external reviewers are the ones that overturned my denial, so I am going to send them that information along with BCBS new refusal to pay and see if I can skip ahead to that level. Why didn't I think of that before?? I needed you all to help me think through this. THANK YOU!! And the link to complain to Duke... yes! I have been complaining through their e-mail system and receiving tons of uneducated responses from entry level folks. I need to kick this up several notches!

 

[Susan in Tennessee]

I'm no help whatsoever but I am rooting for you, I feel your frustration and I urge you to persist! It takes different perspectives to see all avenues of action and you're getting the best of the best right here, no doubt in my mind!

 

[Larra]

You go girl, and go for the punitive damages if you can. You deserve extra for the hell they've put you through.

 

[Stefanie S.]

Today's update... I called NCDOI - the Dept of Insurance - They told me that unfortunately, BCBS is within their right to deny payment since the provider did in fact file the claim 2 days late. They said the guilty party is actually the provider. I asked if this was all still true since I wasn't even approved until June 28. She said the claim period starts from the date of service, which was Jan 24.

I do think the provider has a LOT of responsibility in this because they KNEW I was going to appeal. They ENCOURAGED me to appeal. My surgeon even appealed on my behalf. They got notifications of each time I appealed. So someone dropped the ball, and just never filed the claim like they should have. I have explained this to the provider and to Duke billing numerous times. They always say, "No we aren't responsible because we didn't file because insurance denied. You then decided to proceed with the surgery anyway and signed papers that you were self-pay."

NCDOI said they have no jurisdiction over the provider and can offer me no help there. @DianaCox and @Larra - Am I screwed?

 

[DianaCox]

Honestly I think you need to consult a local attorney. Call the local (county) bar association and ask for a referral to an insurance attorney.