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Coordination of Benefits

Discussion in 'Health Insurance, HMO, HIPAA & Disability' started by lshelton, Aug 12, 2009.

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  1. lshelton

    lshelton Law Topic Starter New Member

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    I have double Medical coverage that I am paying premiums on. Cigna is through my husbands Employer and Blue Cross of SC is through my employer. My husband had a major inpt procedure done and his insurance paid as it should. My insurance is not paying anything on my husbands claims. Even though My Coinsurance through My insurance is 20% and the coinsurnce through my husbands policy is 40% since the provider was out of network. For example I have a claim that the primary insurance left $60.00 to patient responsibility. My coinsurnece through my policy would only be $20 if they would have been primary. But they paid nothing even though they are in network with the provider and BLue Cross of SC is telling me I am responsible for what ever primary leaves as patient responsibility. Blue Cross of SC has applied nothing to my husbands out of pocket. When I call them they are telling me they dont pay as secondary. They will only pay if my primary insurance denies the claim and it is covered under them. I was not told this when I elected to have the policy. I am paying $44/every two weeks for this benefit and I can not get out of it until the end of this year unless I quit my job. I dont know how they can take $1144 per year from me and give me no benefits. I tried to explain if nothing else I should only owe 20% not 40% since I purchased a policy for 80/20 coverage. No where in my benefit book does it state they wont pay as secondary and I will be responsible for what ever primary left as my responsibility. If I would of know this it would have been a no brainer I would not have purchased my Insurance as secondary coverage. Employees dont have a premium therefore I would have my insurance as primary for myself no matter what. I did purchase insurance for both My husband and Daughter. Any advise would be helpful. Thank you
     
  2. cbg

    cbg Super Moderator

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    Did you read the section on coordination of benefits before you elected to double cover? Or did you just assume what they would pay?
     
  3. lshelton

    lshelton Law Topic Starter New Member

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    I did read my entire benefit booklet and I understand how Benefits are Coordinated in Washington State. The provider is required to except the contractual allowance for primary and secondary insurance. The provider is Responsible for taking the highest contractual adjustment. In my case the provider is not applying any contractual adj. I dont know what Florida Law is but My insurance is based in Florida. Why would any employer let someone purchase secondary coverage when they know the employee wont have any benefits. To me this is misleading and does not build an employee/employer trust I am a billing Supervisor at a Hospital and I have never seen such a thing. No wonder insurance companies arent folding very fast with the economy the way it is. I am sure there is a lot more nieve people out there just like me. Never assume your going to get what you pay for.
     
  4. cbg

    cbg Super Moderator

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    How would the employer know that it's going to be secondary insurance? And why is it their responsibility to tell you how it would work? Aren't you an adult? Aren't you capable to managing your own affairs without your employer's help?

    You are free to appeal the decision using the appeal process set out in the policy.
     
  5. Green_Hornet

    Green_Hornet New Member

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  6. lshelton

    lshelton Law Topic Starter New Member

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    The Employer Knows because when you sign up for benefits you have to list if you have other insurance. Apparently my employer goes over this in orientation now because a lot of other employees have complained. But unfortionately I started with my company over 5 yrs ago therefore My employer didnt mention anything back them. This is the first year I have decided to pick up double coverage. I believe people should be fully aware of what they are purchasing. Like I said no insurance in washington state coordinates the way My insurance is out of Floridia. Working in the health industrusy in insurnace billing for over 12 yrs I believed I had a good understanding to how coordination of benefits work. My mistake but now I have to continue to pay for it until the end of this year knowing I am getting no benefits. Plus I also work with the insurance contracts at my Hospital and In Washington state the provider is Responsible for giving the contractual adjustment if they are contracted with the insurance company. My Florida insurance company is not forcing the provider to give the Adjustment and I believe the Provider is in Breech of the insurance contract. My insurance company is taking an adjustment and basing the 80% insurance resp off of the allowed with is the total chgs minus the discount which leaves a higher balance to the patient. IF the provider is not required to apply the contractual discount then the Insurance Company should not be able to take a discount. There 80% resp should be based off total charges. ballowed off of % my NyThe achnftaemplotla
     
  7. cbg

    cbg Super Moderator

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    As I said, then appeal the decision.
     

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