So I went to hospital with my appointment on august 6, turns out my health insurance ended on july 31, and it was too late to know that since I received my bill on august 27 and it was very expensive, close to $10K.
I did not receive any notifications that my insurance ended and the hospital did not check for insurance and I thought probably because I have one.
Now the strange thing is now I am on the same insurance plan that is being paid by my university job partially and it says the coverage dates on it are 1/1/2024 till 12/31/2024.
Is that appropriate reason to submit an appeal?
If yes should I talk to:
A. my university HR
B. benefits department of the university
C. the hospital or
D.the insurance company
Please I just became an adult and I am very new to the healthcare system in the US
4 Likes
If you should have had coverage during the visit, talk to your university or whoever managed the plan at that time. But if you didnāt pay your premiums, canceled your plan, or it hadnāt started yet, thereās nothing to appeal. You need active coverage at the time of the visit for it to be covered.
If you think the policy ended by mistake, contact your university.
4 Likes
Technically insurance dates say that I am covered for whole 2024 year.
But at the time of the visit, I was not aware that my insurance āran outā.
So that means I am screwed here.
3 Likes
Help us understand what āran outā means. Did you quit your job? Did you stop paying premiums? Something else?
3 Likes
Oh,Apologiesā¦So when I went to the website of my health insurance provider on august 10 (after I went to hospital), it said Coverage:01/01/24 to 07/30/24
But now when I go to their website it says Coverage:01/01/24 to 12/31/24
And when I go to my benefits website it says Effective 08/01/2024.
Soā¦ theoretically I should have been covered?
And also I was changing my position at my university but I did not stop paying premiums. I just was in the āprocessingā stage by my HR.
2 Likes
Hi! Iām wondering if you have an HMO plan that may have been assigned to a new medical group or IPA without your knowledge.
I recommend that you first contact your insurance carrier to confirm your coverage. Based on their response, call the hospital where you received these services and update them about your coverage. If your insurance carrier canāt give you helpful information, check with your benefits department to make sure your premium is still being deducted from your paycheck and that nothing has changed. Good luck!
2 Likes
Yes I have an HMO plan. Iām not sure about the medical groups though so I was thinking of my options.
I also kind of thought that insurance company is not my āfriendā here and if I tell them all the details they might try to find a way to make me pay in full.
2 Likes
So I would definitely call the insurance carrier and ask if you have been assigned to a new medical group or IPA or if there has been any change with your coverage. My bet is that you might have been assigned to another medical group. If this is the case, request the new information and submit that to the hospital. If you have the same exact coverage, call the hospital and request that they resubmit the claim to the medical group.
And while insurance carriers are not our friend, they still have the responsibility to provide coverage as mandated by state and federal regulations because they can get in a lot of trouble so donāt be afraid to call them and let them know whatās going on. They should be able to help you figure this out without having to reach out to your benefits department.
2 Likes
Thank you so much! I Appreciate
1 Like
Call your insurance company and ask them to reprocess your claim. It seems you had a lapse in coverage that has been backdated, so it no longer counts as a lapse. The hospital canāt resubmit for this type of denial because the insurance will just deny it as a duplicate claim, which is why they have to bill you.
You should handle this yourself since most hospitals donāt have enough billers with the time to make these calls, especially when they get hundreds of denials each month. Ask the insurance company to reprocess your claim because the denial for coverage termination was incorrect, and you had coverage on that date. Use those exact words when speaking with the insurance representative. They will check your eligibility for that date, confirm you were active, and reprocess it.
After that, call the hospitalās billing department and ask them to pend the claim until the insurance sends them a new remit. Let them know youāve already had it reprocessed and mention how long the insurance rep thinks it will take (usually 30-60 days). If they deny the claim again, they will unpend it, and you will receive another bill. This will keep you from going to collections while you wait for the insurance to process the claim.
It shouldnāt deny again, but if it does, ask the hospital billing department about a self-pay rate and financial assistance. If your insurance says you werenāt covered for that date and refuses to reprocess, also ask about those options with the hospital.
Source: I am a medical biller for a primary care doctor, and I often handle these denials.