About LASHUNDA Expertise Billing,Claims, and resolutions to the following insurance agencies: Medicare, Medicaid, Coordination of Benefits, Most Managed Care such as HMO's, PPO's, Medicare Advantage Plans, Governmental Agencies such as Work Comp and Veteran's Administration. I would like questions that are in regards to Billing and Collections from Insurance Companies. I can also accept some questions regarding accounts sent to Medical Collections. Please be advised that I reside in Texas and most of my knowledge is based on how it works in Texas.
Experience I have worked in the Medical field for 15 years. I currently help to coordinate contracts for a physician group in Texas. I am extremely good with resolving issues with commerical insurance companies. I'm an expert in coordination of benefits between Medicare and Commercial insurance companies.
Question QUESTION: I have a patient who is working, so he opted out of his part B benefits. Now Aetna says that since he's elligible, and didn't get it, that all they owe is the 20% they would owe if he HAD medicare (they didn't disclose this, and he's got the coverage with no discounts to their policy premiums). They say he owes the 80% Medicare would have paid if it existed. Is there any way around that? Does he have no recourse other than a member appeal?
ANSWER: Hi Anne. Thanks for the question. Most all plans require a person to take medicare when eligible. The requirement for a person to take Medicare when eligible is usually written in the summary plan description that the person receives. There are things that can be done except I need a few for details to steer you in the right direction.
What does he have medicare for? ESRD, disability, or age
If he has medicare for two reasons what are they?
Does he work, retired, or out on disability?
Is his Aetna a fully insured plan or a erisa (self-funded) plan?
Do you have any idea when Medicare is supposed to be his primary?
How old is he?
Was he a school teacher?
Answer most of these questions and I probably can give you some suggestions.
Thanks,
LaShunda
---------- FOLLOW-UP ----------
QUESTION: He's elligible due to his age. He has since lost his job, but he was working on the date of service. However, I don't think he's accepted part B's coverage yet. I don't think he can afford to, but once he can, they may back date the coverage huh?
If Aetna's not ERISA, then are ya thinking that I should involve TDI? He turned 65 last July, but no he's not a teacher.
Answer Hi Anne. Thanks for the follow up. He can certainly file a letter of good cause and pay his back premiums (which about 1100.00) with social security. They will retro him to the original effective date of July 2008. If he was working at the time of the date of service than there is no way medicare would be primary.
You may want to call Aetna and get a supervisor to bypass customer service. You can also contact the Aetna provider rep that is responsible for your office for help with getting your issue escalated.
You can also try filing an appeal that states that although he didn't get Medicare when eligible, Aetna would still be his primary ins based on the fact he was working.
Make sure you've exhausted all avenues before filing with TDI.
Yes, if it's not ERISA but a fully funded plan in Texas, you can file the issue to TDI.
I would try contacting the provider rep....AFTER...you have filed an appeal.
