Dealing with resubmittal of Provider claims

December 22, 2020 1:46 PM

We have to get providers to resubmit all of our health insurance claims (already paid) to the another insurer during the past 4 months. Have you had to do this? What are your tips?

My wife has had a insurance through work (Insurance B), but due to a misunderstanding, I added her to my plan at work and have been submitting all claims through my plan (insurance A). Claims have been paid by Insurance A and we have been paying co-insurance/copays (my wife is pregnant) to providers, which is to a tune of a couple grand.

Fast forward four months and these claims are all now in pending state by Insurance A since this has all gone through to Coordination of Benefits. Insurance B is actually the primary (i.e the one that we never submitted) and needs to be processed through them before secondary insurance (Insurance B) (which already paid the claims) pays. We don't really care about resubmitting through the Insurance B but want to make sure we're not stuck with a huge bill. (would e nice to have a lower out of pocket though)

My wife has to get her providers to resubmit insurance claims to Insurance B, but the providers aren't in a hurry since they have a zero balance.

Her thought is: for future claims have her providers bill Insurance B. For the claims already submitted, wait until the insurance company tries to claw back their payments, and then they will reach out to us to give a new insurance.

A couple other wrinkles:
1. Very possible these providers are out of network now
2. Insurance B has lower deductibles,copays than Insurance A
3. I paid most of these copays/deductibles already through my FSA

There are at least 6 different providers that we have to handle, some which are only a couple hundred dollars to a couple thousand dollars of claims.

Have you had to go through this? What did you do? How'd you handle it? And I know blah blah US insurance sucks etc.

TLDR:
1. Insurance A claims submitted
2. Insurance A paid claims
3. Insurance A now saying can't pay claims until Insurance B pays
4. Insurance B needs to get the claims so that they can pay them
5. Insurance A will deal with leftover and handle pending claims
What do you do?

posted by sandmanwv to Health & Fitness (3 answers total)

Have worked in billing on the providers side. What typically happens is Insurance A will either request a refund from each provider or they will recoup their payments on those claims when they pay other claims to the provider. So, say they owe the provider $100 for John Smith. Say they paid $75 on sandmanwv. They will pay $25, and recoup the $75 paid. Sandmanwv claim will then be back on their books and John Smith claim will be paid. OR they wait for each provider to issue refunds. These providers cannot rebill to Insurance B, until Insurance A's payments are cleared from their books. At least that's how it worked where I worked. Once Insurance A is aware the coordination of benefits has been updated they should get to work on this. Hopefully Insurance B has a lengthy timely filing deadline, so they will process the claims once they can be submitted.
posted by txtwinkletoes at 2:21 PM on December 22, 2020

Best answer: I've been dealing with this exact situation. For out-of-network providers, I've gotten a notice from the insurance company saying, basically, "Remember that claim check we sent you? Give it back." I had to submit to Insurance B (which in my case has no OON coverage, making this a pointless exercise), get rejected, and then resubmit the claim with the rejection EOB to Insurance A. For one provider, I did it myself; for the other provider, I gave them a call and they did both resubmits, but I had to kind of manage the process. They were nice about it, though. I don't think it's a big deal to them.

For an in-network provider, I discovered the situation because I got a surprise bill from the provider. Sorting that one out was as simple as calling the provider and clarifying my insurance coverage.

I don't think it matters whether your providers' in-network status has changed. What matters is the status on the date of service.

Regarding FSA, I happen to have paid out of pocket for these appointments, so I'm just waiting for the final EOB to submit to my FSA. However. If I were in your shoes, I'd just not worry about it—the important thing is that you've retrieved those dollars from the FSA already—and make sure to have my (final) EOBs on hand in case some auditor comes calling.
posted by the_blizz at 4:10 PM on December 22, 2020

Best answer: This is fixed by the provider. They need to cancel the original claim with Insurance A and submit a new claim with Insurance B. Once the claim is processed by Insurance B, the provider will then submit a claim for secondary coverage with Insurance A (including a copy of the EOB from Insurance B showing what they paid). Coverage is determined by the date of service, not the date the claim is filed. If you are lucky, Insurance A might pay for the Insurance B copay and you will end up ahead. (No idea what do about the FSA at that point but I would wait to worry about that when you get there)

If the provider does nothing, then sooner or later Insurance A will notice the problem and tell the provider to repay them the money. The problem is that if A takes too long, it may be too late to submit the claim to Insurance B. While providers need to file on a timely basis (anywhere from 90 to 365 days), insurance companies can take their own sweet time about clawing back their money.

So I would suggest that you contact the billing office at the provider asap and let them know what happened. If you don't see an adjusted EOB within 30 days, call again. Keep notes. In fact, if it is larger office with an on-line portal, I would do it that way so you have a record of your request and follow-ups. You don't want them to bill you if they take too long and A demands their money back and B fails pay because so the claim is too old.
posted by metahawk at 8:19 PM on December 22, 2020