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.
Hi Lashunda, thank you in advance for your help and info. My question is the following –
I have an individual PPO health insurance plan with Blue Cross Blue Shield of NJ. I had a special surgery that was performed in San Diego in Sept 2008. The hospital and doctors are in-network with California Blue Shield, so the surgery and hospital stay was processed as in-network. The provider sends all claims to BCBS of California, who in turn transmits the claims to BCBS of NJ.
So far most of my claims have been processed and the EOB’s sent to me have been covered by the insurance company.
I have the following questions
1 - In general, is an Explanation of Benefits considered a legal document for an in-network provider ?
The customer service reps of Blue Cross Blue Shield frequently make this statement to me over the phone.
2 – Last week, the providers billing office told me they found the following error that they themselves made. The billing office credited my account with an insurance payment from another patient who also had BCBS, and had the same test with the same date of service as me. They credited the payment in October 2008 and realized their error in June 2009. So now they are telling me that the insurance payment for this claim is due. To make matters worse, BCBS of California never transmitted the claim for processing to BCBS of NJ. The provider claims they sent the data for the claim over to BCBS of California and is resending the claim to BCBS of California again.
If either BCBS of California or BCBS of NJ does not accept the claim now because of the time frame elapsed, am I responsible for this ?
I understand from your profile you are very familiar with Texas, so I am asking for your general opinion on these questions. Thank you for your help.
Edward
Answer Hi Edward. Thanks for the question. I'm not quite sure why the insurance company is stating that the eob is a legal document. I guess I don't understand why that's even a question. It's not a legal document but you should recieve a eob of your own.
In each physicians contract with an insurance company they have a set of rules. Most of health plan contracts require a physician to not bill members for physician errors such as timely filing of a claim. It is possible that a payment for another patient was posted to your account in error. It's human and computer error sometimes. It can take awhile to find out that the payment was posted incorrectly. However, I can't tell you that you wouldn't be responsible because each office bills differently. But, I can tell you that you shouldn't be responsible. You're eob will also reflect if the balance on the claims are your responsibility or not. The process you are speaking of is the normal process for BCBS. You have to submit the claim to the local BCBS and they will forward it to what they call the home plan.
If you're curious if you will be responsible I suggest you contact BCBS (your home plan BCBS) and ask for filing deadlines on the claims.
