Medicare, Medicaid, Life and Health Insurance/insurance denies payment

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QUESTION: First let me say thank you for any help you can offer me.  I am asking on behalf of my 73 year old mother.  Her memory has begun to deteriorate and I have very recently become aware of the need to begin assisting her in certain areas.  

My mother has within the last few months begun to suffer from extreme leg weakness.  She had an episode in June of this year and was taken  to the ER. She was unable to walk and taken into the ER by wheelchair.   They could not find the cause and sent her home.   The weakness subsided somewhat after 24 hours. She has since had 3 or 4 more milder episodes.  Then last week she had another episode of extreme weakness and numbness in her legs.  She was taken by a friend to the ER.  They admitted her, which upset her greatly and she was highly upset about it. Again, her short term memory has seem to deteriorate a great deal in the last months and the stress of this situation made it worse I believe. The nurse even mentioned to her that she was repeating herself alot.   They checked her legs, and said they couldn't find a cause for the weakness.  They then called in a Neurologist who ran 2 MRI's on her.  Negative results.  They acknowledged she was highly agitated and upset and gave her something to calm her down that evening.  
My mother has been on heart medicine for palpitations for decades. She is also on blood pressure medication and has two leaking valves.  She was convinced the issue was her heart, though again, she has become rather confused as of late.  they then called in a cardiologist who ran more tests and advised her that her heart was fine.  They advised that they would be releasing her but not before the case worker came in and advised that the insurance had denied payment.  My mother is now distraught about a bill she was not prepared to pay.  I fear she will not seek medical care in the future when she needs it because she will be afraid that they wont pay.  The case worker has scheduled a doctor Peer to Peer call between the doctor and the insurance company to see if he can explain why he admitted her and ran the tests.  She has also advised us to call the insurance company and speak with them.  It is a medicare replacement company that I believe is an HMO because  she has to pick from certain doctors.   I DO feel they should pay.   she was not happy about being admitted to begin with.   Any advise or thoughts you can give me on this would be appreciated so very much.  Again,  this is all new to me as she has been fine taking care of everything herself up until now.  I fear the stress is making the memory issues worse.

Thanks so much!
Beth

ANSWER: Hi Beth

I am sorry to hear about your mother.  From what you stated, it sounds like the admission was not eligible for inpatient status which means that it is possible the visit should have been in observation status.  If that is the case, the hospital will need to refile the claim to the Medicare HMO according to their guidelines.    I would begin with calling the insurance company to find out why they denied the claim and also find out if they applied the charges to the patient responsibility. If the insurance denied due to incorrect billing, request a conference call between the insurance company and the caseworker so the that the issue can be discussed by all parties for resolution.  Most likely, the only way it would be your mothers responsibility is if her coverage changed (provide the correct insurance card) or some information required has not been provided. If all efforts have been made to have the insurance company pay and the balance is still your mother's responsibility, then you should contact the hospital to make payment arrangements. If your mother is on a fixed income, it is possible that she may be eligible for charity care.  Depending on her income, she may be asked to pay some or none of the billed amount.

I hope this helps.  Let me know if you have any more questions.

Joy

---------- FOLLOW-UP ----------

QUESTION: Thank you so much Joy.  I was under the impression from the case worker that they did bill as observation.  Possibly that is the problem?  

 Not certain on that however.  I have found out it is a PPO.   The insurance company is claiming that the tests (MRI, EKG, ect) could have been done on an out patient basis and weren't necessary as an overnight hospital stay.  She (the case worker) commented that there were notes in the submitted information that stated my mother's symptoms had subsided a little during her time in the ER.   However, I am uncertain why they would have admitted her if that were the case, nor am I certain if this is the reason they are denying payment.  We will call the insurance company on Monday together and see what can be found determined.  I would assume that we can ask the insurance company how this was billed and what needs to be changed to have payment approved ????  also, I wonder, even if insurance doesn't pay, would the "Coventry Health adjustment" still be applied to lower the total due?  

I cannot tell you how much your assistance in this is appreciated.  I am going into this blind.  It is an eye opener as to what I need to begin familiarizing myself with as it pertains to my mothers current health status, both physically as well as mentally.

Kindest Regards, and many thanks
Beth

Answer
Beth,
FYI...Observation is considered as outpatient so if the insurance states the services could have been provided on an outpatient basis then it is likely that the original bill went out as in inpatient. But you will find out for sure once you contact the insurance company.  Also, most of the time when Medicare Advantage plans deny, they deny the entire claim with 0 adjustment but it sounds like the denial was due to billing error so I would suggest you refuse to pay until this issue is resolved. The hospital/doctors need to eat the cost due to incorrect billing or make the proper corrections, resubmit the claim and get approval for payment if they want to get paid.

Good luck! I am sure everything will work out in your favor.

Medicare, Medicaid, Life and Health Insurance

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Joy B. Hicks, MBA, CPM

Expertise

As a Medical Office Expert, I can answer any question related to the medical office from the prospective of hospital and physician office staff and patients.

Experience

I have been in the medical office field for 12 years and also have a blog that provides advice, information, and tips about the medical office.

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medicaloffice.about.com
askamedicalbiller.com
allthingsmedicaloffice.blogspot.com

Education/Credentials
Certified Practice Manager
AAS Business Administration
BA Health Care Administration
MBA w/ healthcare specialization

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