Professional Help Navigating Health Insurance Disputes

Claims/Providers Forum
1

Is there a professional I can hire to handle health insurance and medical billing disputes? I don’t want to sue the insurance company, but I’m willing to pay someone a few hundred or even a few thousand dollars to take care of these disputes for me.

Here’s my situation:

$500 - I had two virtual visits with a PCP through Anthem’s website, under their Virtual Care section. The page said it was included with my plan and showed an Anthem logo. Now, Anthem claims the provider was out-of-network.

$15,000 - My wife was on Aetna, and I was on Anthem when our son was born. We added him to Aetna before leaving the hospital. Then my wife changed jobs, and we used the QLE to add both her and our son to my Anthem plan. The hospital says Aetna approved the labor and delivery claim. But Aetna now says that Anthem should have been the primary coverage for our baby. Anthem disagrees. The hospital wants $15,000. I’ve spent hours on calls, and there’s no resolution.

$100,000 - My PCP referred me to an in-network specialist. The specialist said I needed surgery urgently. I called the insurance company and hospital to confirm everything was approved. They both said it was. Four days after the surgery, I got a letter saying the surgery was approved, the hospital was in-network, but the surgeon wasn’t. Now, I have two pending bills totaling over $100,000.

I think I can eventually resolve these with enough calls, but I’m overwhelmed. Since my son was born, my biggest job has been dealing with medical billing. I wish I’d just been rushed in with a real emergency—then at least I wouldn’t be facing six-figure bills.

I’ve considered services like Yohana.com, but I’m not convinced they’re competent enough. Hiring a personal assistant on Upwork crossed my mind, but I don’t know how to ensure they’re trustworthy and knowledgeable about insurance.

I need someone I trust to handle these disputes and tell me what I really owe. ChatGPT suggested a medical billing advocate—does anyone have experience with that? I’m looking for a long-term solution for this issue and the next one that comes up.

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2

Always check the EOBs for all your claims on your insurance website, no matter what bills you receive.

If the EOB says you owe money you shouldn’t, file an appeal with your insurance. If the EOB shows you’re not responsible for a charge (like the out-of-network physician in #3), show that to the providers who are billing you.

For #2, Anthem should be retroactive since you added your child within 30 days of birth. Your child also had dual coverage during the first 3 weeks—added to your wife’s plan first. You need to file coordination of benefits forms with both Anthem and your wife’s old plan. When there are two active plans, primary coverage is usually determined by the birthday rule (the parent whose birthday comes earlier in the year).

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Thanks. What you said about coordination of care matches what I’ve read before. I didn’t know how it worked when we signed up for Anthem, but it would be fine if that’s the outcome. The person I spoke with at Anthem disagreed, though. He read something that said the baby’s coverage is only retroactive under the mother’s plan. He said he opened a case and I’d hear back later, so maybe Anthem will say he was wrong. Another person mentioned that because we used my wife’s coverage loss as the QLE and not the baby’s birth, the baby’s coverage might not be retroactive.

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I saw LizzieMac mention that if the QLE was for loss of coverage instead of the baby’s birth, then the child wouldn’t be added retroactively. What a loophole! I wonder if you can change the QLE now. If not, I guess Anthem is correct since LizzieMac, who’s a mod, is probably right.

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Here’s my take on the second situation.

Did you officially add the baby to the mom’s Aetna plan through HR? If your wife got coverage through her work, you need to tell HR about adding the baby and provide any documents they ask for. The 30-day courtesy coverage is just to start paying claims, but if you don’t properly add the baby, claims get denied after 30 days. Many employers need proof like a birth certificate, so I want to check if you followed the HR process to add the baby.

When you added the baby to your plan, did you use the QLE of the mom losing her insurance, not the baby’s birth? If so, then Anthem wouldn’t backdate the coverage to the baby’s birth. It would start the first of the month after you told HR.

There might be more to the story regarding your wife’s loss of benefits and these retro denials. If you didn’t officially add the baby to Aetna through HR, that’s why the charges were denied. If you did add the baby, I wonder why they still denied it. It could be linked to FMLA or benefit continuation while on leave.

Did your wife take FMLA at the end of the pregnancy or after the birth? FMLA requires benefits to stay active while someone is on leave. Arrangements must be made for paying the employee’s part of the benefits—either during leave or deducted when they return. If an employee doesn’t return to work for at least 30 days after FMLA ends, the employer can try to recover what they paid.

I don’t think they can just retroactively end coverage before the leave starts, but if payments weren’t made, that might lead to coverage being canceled. Maybe someone with more FMLA knowledge can add to this.

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6

Thanks for thinking this through.

Yes, I called HR and added the baby to my wife’s Aetna plan. They confirmed they cover the baby but believe they are secondary. From what I’ve read here and elsewhere, I think they are correct, and Anthem is wrong. I didn’t know how this worked when we added the baby to Anthem, but I’ve made sure Aetna, Anthem, and the hospital all have the member IDs and other info for both policies.

When we added the baby to Aetna, the QLE was the baby’s birth. When we added the baby to Anthem, the QLE was my wife losing her coverage. If that affects the retro coverage, then Aetna is wrong, and Anthem is right.

The denial reason is that their outside auditor believes the baby has other primary coverage and they don’t have the EOB from that primary. So far, Anthem just states the effective date is when the baby was three weeks old. I think that means they won’t issue an EOB or will deny coverage based on that date, but Aetna disagrees. I have an open case with the coordination of benefits team at Anthem, but I’m not sure if the outcome will be an EOB or just a statement confirming the effective date.

My wife’s employer offers paid leave, which she took starting the day of the birth. I’m not sure if that means she officially invoked FMLA or not. She had a fixed contract that was set to end when the baby was three weeks old, so both coverage and her paycheck ended then.

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7

Call the insurance company and dispute the network status for the virtual PCP. They likely booked with incorrect information.

Ask about Coordination of Benefits. Inquire if they have a retroactive policy for newborns in the first 30 days of life. Check whether the claim is processed under the mother or the baby. Also, ask what the effective date is for both.

Find out if your plan allows sending ancillary claims at the in-network benefit level if done at an in-network facility.

Call your insurance and ask for the patient responsibility on each claim, especially if you don’t have the EOB. Explain that you have $100,000 in pending bills and want to verify the claim status.

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8

Here are my suggestions for getting help:

If the plan is fully insured, file a grievance with your state’s department of insurance.

If the plan is self-insured, file a grievance with the federal Department of Labor.

Begin by appealing the insurance company’s decision. If you still receive a denial, then file a grievance.

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9

Thanks. How do I find out if my plan is self-insured? It’s a company with a few thousand employees, so I think it probably is but I don’t know for sure.

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10

Given that size, I would be surprised if it isn’t self-insured.

HR would know for sure. If you have a care coordination team, like APTA or Accolade, that’s a good sign (though not definitive). Some carriers manage self-funded plans through a different division. For example, UHC’s self-funded division is UMR, and Aetna’s is Meritain. If you see UMR or Meritain as your carrier, it’s definitely self-insured.