Coordination of Benefits issue.

parker0507

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Hi,

My practice where I work wanted to ask if anyone has had a problem with this said scenario:

Patient comes in with dual insurance from parents it takes them and the insurance to finally figure out who is primary and secondary insurance. Divorce Decree needed to be sent in.

We needed to do corrected claims as the primary insurance we original billed is now secondary, we had no Authorization for what is now the primary insurance does not cover said diagnoses with out authorization. Per the claim we can't bill the patient. We are not able to get retro Auth from the now primary. Do we have any course of action or are we out the money. How do you prevent this from happening when the parents have an issue with the COB.

Janelle B
 
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Typically the birthday rule gets applied, but in situations such as yours, the parent(s) really should have told you about the circumstances regarding primary vs secondary per the court order. They should have also notified their respective insurance carriers after the court order was issued, but of course, we don't live in a perfect world. Insurance verification done prior to the visit might help to catch a few of these, as long as the payers know who's primary and who's secondary.

As far as the COB problem you're dealing with, was the court order in place before the visit (I assume it was)? Given the circumstances, I don't understand why a retro-auth wouldn't be given. It's not the provider's responsibility to facilitate COB issues between payers and parents when a court order exists. Nor is it the provider's fault that the COB wasn't done in a timely manner. There is absolutely no reason that you, as a provider, should be penalized here.

I wouldn't attempt to appeal through regular channels; you need the "higher ups" at the payers to be involved. I would contact your provider rep at the "now" primary payer and escalate this. Whenever we get push-back from payers in similar situations and our provider rep can't get anywhere with fixing it, we typically contact the "higher-ups" at the payer. Something along the lines of "Because our attempts to resolve this situation informally with you have failed, we will be escalating this account to our legal/contracting department(s) for review..." Yes, it's totally passive-aggressive, but we have never had to actually follow through with it. Payers don't like to hear about our legal department, nor do they like the thought of loosing their contract with us, especially when all they need to do is approve a totally justified retro-auth.

I wouldn't let this one fly by if I were you. The payer needs to be held accountable for such a shady practice.
 

April.Kleck

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Policy Change

Perhaps it needs to become an internal policy change. When registering a pediatric patient if it is found that the patient has two forms of insurance two questions should immediately follow.
1. May I ask if both parents live in the household? (Usually this can be assumed depending on the last names of the parties)
2. Is there a court order involved indicating medical support? (This can also be found as a clause in most child support orders.)

Depending on how the questions are answered are how you would proceed.

As far as not billing the patient I would have transferred the balance to the patient at first denial.
 
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