Never thought being over-insured would be a bad thing.
August 21, 2014 9:48 AM   Subscribe

Looking for any experiences, counsel, legal referrals to deal with health insurance clawback/SNAFU that's has my blood boiling.

Rather than being under-insured, apparently our problem is being *over-insured*

Recently received notice from health care providers that we "owe" a significant amount of money for healthcare delivered in 2012 and paid at the time by our insurance, which has since clawed back the payment.

The situation as I understand it:
> Both myself and my spouse have insurance through our employers and have paid for coverage for each other as well. We though this was "smart" to pay for "extra insurance"
> My spouse incurred substantial medical expenses in 2012 and these were paid for my my insurance company A. Big healthcare costs were a new thing for us as was/is navigating healthcare insurance, but we'd thought we'd been very conservative in paying for two sets of policies
> Company A just informed healthcare providers that since spouse was also covered by Company B back in 2012, they are retroactively denying claims, years later.
> Company B says they have no obligation to pay since too much time has past to make a claim for 2012.
> This appears to leave us on the hook for many thousands of dollars of healthcare that had been previously paid.

I'm shocked, livid, and angry.

Has anyone been in a similar situation or does anyone have any advice on how to best navigate with the obvious goal of not paying for services we believed we were doubly insured against?

Does anyone have a referral for a lawyer in the Seattle area that could assist here?
posted by donovan to Law & Government (10 answers total) 2 users marked this as a favorite
Yep, lawyer.

Although, in retrospect, you should always use your primary insurance first, e.g., the one you're getting from your own job.
posted by Oktober at 9:58 AM on August 21, 2014 [1 favorite]

Response by poster: Yes, "in retrospect" I get that . . . if at any point over the *years* this had been surfaced as a question by anyone we would have approached things differently.

I only see frustration and failure trying to untangle this by myself so am hoping there are some magic/secret words/phrases/clauses that can be invoked and will gladly pay a lawyer to help here.
posted by donovan at 10:13 AM on August 21, 2014

Company B says they have no obligation to pay since too much time has past to make a claim for 2012.

This is likely the best point of pressure you've got. Have you explained the situation and asked really nicely? You were paying for coverage, and it's a failure only on coordination of benefits, not fraud - so morally they should pay up. Legally, unfortunately, they probably specifically exclude claims that are not billed "promptly" (do they?) but it's possible that a case manager may be able to sort this out for you before you get to a lawyer.
posted by RedOrGreen at 11:00 AM on August 21, 2014 [1 favorite]

Did company B ever receive a secondary claim from company A? If so, you may be able to ask company B to reprocess those claims and pay as primary. Timely filing shouldn't be a issue in that instance.

Also check with the department of insurance for the state your in, sometimes there are limits as to how far back insurance companies can recoup money. Texas only allows 6 months from the date of the insurance payment for that company to recoup their money. After that, they are out of luck.
posted by Attackpanda at 11:17 AM on August 21, 2014 [1 favorite]

Following up Attackpanda, your claims to company A should have disclosed that the patient also had insurance with company B. This is a standard question on insurance forms.
posted by JimN2TAW at 11:26 AM on August 21, 2014

This happened to us. Honestly it was a complete fucking nightmare, incredibly stressful - it kept me up at night. The amounts of money involved are large and it's scary. One day you find out, surprise! There's yet another way to be screwed over by the American health care system! Here are some confusing and arcane rules that can fuck you up financially years after you thought it was all squared away!

The way we coped was with professional help. We asked around and found/hired a professional fiduciary. This is basically a person whose job is to deal with financial nightmares like this for people. Think of an elderly person who doesn't have family who are willing/able to help with insurance stuff, or a seriously ill patient who might accumulate hundreds of thousands of dollars of confusing health care claims. Professional fiduciaries get a power of attorney from you to represent your financial interests with the health care companies, and they have the expertise to deal with this - they know the right words to use, how to ask for old claims, how to check all the paperwork for mistakes, how to work with the doctors' offices, and so on.

Here's more at the Professional Fiduciary Association of California website. Reading the site, it looks like it's more common for fiduciaries to work with trusts and wills, but the person we worked with had lots of experience with health insurance.

Reading over this I realize that I sound like an ad for fiduciaries. Getting one was really useful for us, so I guess I'm kind of a cheerleader. Not having to worry about the nightmare was worth it. It wasn't cheap, I think we paid about $1K, but it cost much less than paying the rejected health care claims.

And for future reference, don't have two health insurance policies.
posted by medusa at 12:48 PM on August 21, 2014 [8 favorites]

One point to consider is that it is almost never the insured who decides which company should be billed, it is the provider - the doctor or the hospital providing the service. They will normally ask if there is health insurance and will know which one to bill if there is more than one. Did you disclose both policies when receiving the service?
posted by yclipse at 1:48 PM on August 21, 2014 [3 favorites]

I agree with Yclipse. I've carried two insurances off and on for most of my life, and am always getting coordination of benefits forms. Usually the insurance companies sort it out themselves, sometimes I have to provide more information, but I have Never been the decider.

A fiduciary might not be a bad idea.
posted by checkitnice at 2:53 PM on August 21, 2014

Attackpanda said: "Also check with the department of insurance for the state your in, sometimes there are limits as to how far back insurance companies can recoup money. Texas only allows 6 months from the date of the insurance payment for that company to recoup their money. After that, they are out of luck."

New York State also has a limited time period for insurance companies to recoup payments. When we had a situation somewhat similar to yours, we contacted the New York State Attorney General's Health Care Bureau. They were very helpful, and the situation was resolved in our favor. It was, however, an incredible headache!

Fyi, the reason for the clawback in our case was different, but the similarity to your situation is that our insurance provider decided that claims they had paid years earlier for treatment for one of our children (Child A) should not have been paid. To recoup the funds, they approved claims for recent treatment for our other child (Child B), but deducted the amounts they claimed were improperly paid years ago for Child A's treatment from the current payments due us for Child B's recent treatment! That is wrong on so many levels. And on top of all that, they were completely wrong that the claims paid years ago should not have been paid.

Anyway, getting the Attorney General's office involved was incredibly helpful. But in your state, the Department of Insurance might also be the place to try. Maybe call both of them!
posted by merejane at 3:52 PM on August 21, 2014

I spent some time looking at the wa laws and rules. These may be relevant, but you should find someone qualified to be sure.

Coordination of Benefits.

Overpayment recovery for carriers.
posted by jeffamaphone at 11:31 PM on August 21, 2014

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