Did you know…that the State of Connecticut has a department called the Office of the Healthcare Advocate? The Office's mission “is to assist consumers with healthcare issues through the establishment of effective outreach programs…related to consumer rights and responsibilities”. Their job is to help consumers solve problems with their insurance plans.
When we believe we are right and the insurance carrier is wrong, and we are getting nowhere with the carrier, we have turned to the Healthcare Advocate for help. Our office can be appointed to represent the member, and we will provide all of the necessary documentation and work with them toward a resolution, or the member can deal directly with them.
The following is a brief summary of the last two times we asked for their help:
An employee was bit by a dog while vacationing in New Hampshire. He went to the closest urgent care center for treatment. The facility was unfortunately out-of-network.
His insurance plan clearly stated that urgent care would be covered the same whether in- or out-of-network, subject to a $75 copay. He paid the $75 copay in good faith, expecting that the carrier would pay the balance.
He signed a statement that he would be personally responsible if the balance was not paid, which is typical of many providers.
At first, the carrier paid a small amount claiming the procedure code was not correct. We had the facility reprocess the charges and then the carrier paid another portion of the outstanding bill. The carrier then told us that they pay out-of-network urgent care centers subject to the out-of-network deductible and coinsurance.
We pointed out that their benefit summary clearly states it is subject to the same in-network $75 copay, and the response was that they did not mean that and referred us to the out-of-network benefit description in their certificate. We pointed out how deceptive their benefit summary was if that was the case. We pushed it further up the ladder and they paid a little bit more, but it still left a balance for the employee. They told us that if the employee didn’t sign the personal guarantee he wouldn’t owe them anything.
At that point, I went to the Health Advocate. A few days later, the carrier agreed to pay the entire balance due, claiming it was a misunderstanding.
I’ve asked for something in writing from the carrier that future members won’t experience the same problem and am still waiting for that documentation.
The second situation involved an employee who was an inpatient at a rehab center when his employer changed insurance companies.
The medical plan had a high deductible, which he paid with the first carrier, and then the new carrier charged a second high deductible for the same stay.
The facility billed the second carrier as if it was a new claim and the new carrier charged another deductible.
The original carrier refused to acknowledge that it should pay the entire claim because the stay started when they were the carrier in force, and the second carrier refused to acknowledge they processed the claim incorrectly.
The facility would not cooperate because they billed two carriers for the same service, which is not quite the right thing to do.
In comes the Health Advocate’s office and suddenly everyone cooperates.
The moral of all this is that the Healthcare Advocate is a great resource to go to when all else fails. We solve the vast majority of problems by going up the ladder at insurance companies, but it’s nice to know that the Health Advocate’s office is there as a resource. Never hesitate to call our office for help with claim and administrative problems.
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