How to get help beyond insurance company & medical provider?

I work in HR, and I have an employee (a 30-year-old male) who is in a tough situation, and I’m trying to help him. Due to several issues between the insurance company and the medical provider, he’s being told he owes over $28,000 for a lifesaving inpatient hospitalization.

Is there a state agency in Wisconsin that he can contact for help and intervention? I think I read about it in some posts here, but I can’t remember the name.

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Can you share more details about the situation? Was this a denial for services not covered under the policy? Did he go to an out-of-network provider or facility? Was this a true emergency, like being admitted to the ER?

These details can help determine where the issue lies. Since you work in HR, have you involved your broker to see if there was a policy violation by the insurance company or if it’s a provider issue?

In general, if you feel the insurance isn’t following its policy, you can file a grievance with the state department of insurance for fully insured plans. For self-insured plans, you can file a grievance with the federal Department of Labor. If you have a self-insured policy (where the employer pays claims as they come in and usually buys stop-loss insurance), you, as the employer, have some responsibility to ensure the contract is executed properly. I wouldn’t recommend calling the DOL yourself; instead, work with your broker to find a compliant way to handle the issue. If the DOL investigates, there will be an audit.

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Sure, it was a true emergency where his kidneys were shutting down. This was not a known or previous medical condition. Anthem originally denied the claim in August 2023, but the employee never received a notification about this denial. He is not aware of anything being mailed to his home.

The employee didn’t receive any bills from the hospital because he thought he had met his out-of-pocket maximum from other bills earlier in the year.

In January 2024, the hospital rebilled the insurance company after recoding the expenses. Again, the employee was unaware of this.

In May 2024, the hospital sent the employee a letter saying that the insurance company wasn’t paying anything. The employee reached out to ShareCare, a third-party administrator, for help. They communicated with him for the next several weeks. On July 11, 2024, ShareCare called to inform him that the bill was still incorrectly coded and needed to go back to the hospital.

On August 28, 2024, the employee received an email from ShareCare saying Anthem was still denying the claim due to it being deemed medically unnecessary. He needed to file a second-level appeal. The employee contacted the hospital for all his medical records related to the incident.

On September 5, 2024, the employee sent an email with all the medical records to the insurance company.

On October 1, 2024, he received a letter from corporate counsel indicating that the claim was denied and the ruling was final. This time, the reason for denial was that he was past the six-month mark since the first appeal was denied.

Now, the employee has been given three different reasons for the denial of his claim. He needs to figure out his next steps, whether that involves seeking help from a state-level organization or consulting an attorney.

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I would definitely contact the state department of insurance because of the three denial reasons. The provider is at fault if the claim was incomplete or not filed on time. The member should have an Explanation of Benefits (EoB), even if the claim was denied, in their online portal. They should also receive these documents at their address on file, unless they opted for paperless statements.

Assuming this is in-network, the provider is responsible for filing claims on time and completely with the insurance. If the insurance company did not notify the employee of the claim denial, either in the portal or by mail, they are at fault as well.

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Thank you! I’ll share this feedback with the employee and help him get those EOB’s from his online portal. I’ll have him double check that portal in case he missed an online denial letter. You’d think if a company is denying a claim this large they would be sure to mail the physical letter to the person’s home as well but that’s a different topic I guess.

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Is your plan self-funded or fully funded? If it’s self-funded, you hold all the power, so you can tell the TPA you want to cover it. If it’s not self-funded, then your insurance commissioner’s office is your best option.

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No, it’s fully funded and we are a super large international company.

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You can file a complaint with the insurance commissioner in the state where the plan is headquartered. They might be able to help, but it sounds more like a provider issue.

Was the hospital in-network?

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Yes, the hospital and all of the providers were in-network. Do we just google insurance commissioner for Wisconsin (or wherever Anthem is located)?

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Hold on; let’s make sure we have the terms right. If this is a large international company, it’s most likely self-funded. This means the company actually pays the claims while Anthem just administers the plan. A fully funded plan means you buy the policy, and the insurance company pays the claims. You can check the evidence of coverage book for this information.

If it is self-funded, your company can simply decide to pay the claim and be done with it.

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Okay, maybe I"m wrong and don’t know if we’re self funded or not. Unfortunately, I’m very low level within this corporation. I’m HR at one of the thousands of plants in the U.S., and tens of thousands throughout the world. I don’t stand a chance of helping him out since the final denial came from legal counsel within our corporation.

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I had a complicated surgery covered by insurance, but they denied it despite pre-authorization. The hospital exhausted all appeals and sent me a bill for about $100,000. I called the HR department to get insurance information so I could start an appeal myself, but HR just said, “That should be covered; I’ll give them a call.” The claims were processed and paid within 2-3 days.

I’m not sure who at the employer needs to contact the insurance company about unpaid claims, but it seems HR can help push it through.

If all else fails, you could contact the insurance commissioner, but that might take a while.

Good luck! I hope they just say “oops” and pay it.