Blue Cross and Blue Sheild re-adjust a bill from two years ago. Telling me I own a provider more money. WHAT?

Question

Today in the mail, my heath insurance sent me a letter saying- THE CLAIN FOR THIS PATIENT WAS REVIEWED BASED ON ADDITIONAL INFORMATION RECEIVED. WE HAVE COMPLETED AND ADJUSTMENT, AND HAVE DETERMINED THAT AN ADDITIONAL PAYMENT IS NOT AVAILABLE. **YOUR TOTAL REPONSIBILITY TO THE PROVIDER OF SERVICES IS $105.96 *

Do I have pay this money, since it been two years ago? CAN THEY WRITE IT OFF? What does ADDITIONAL INFORMATION RECIVED mean? HELP! THIS IS NOT RIGHT.

Answer 1

Likely yes, you are responsible for it.

I'm GUESSING what happened is the provider didn't submit all the charges at that time. Most of the time, insurance companies require charges be submitted within 6 - 12 months. Because of the late submission, they're declining the claim, and you're responsible for it.

If the provider wants to write it off, they can - but likely they won't. They'll probably send it to collections.

You'll have to call 1. the insurance company and 2. the provider, to see if my "guess" about what happened is right.

Answer 2

It's possible when the claim was initally billed, it was billed wrong - meaning, for the purpose of explanation, let's just say you had a complete physical, but the doctor marked off the wrong box on the superbill, and a sick visit was billed (at often half the price of a physical). Somewhere down the road, there was an audit - either by the insurance company (who reserves the right to check patient charts against what's being billed at any time - even just for funsies.) or internally. (Someone had your chart and happened to catch the mistake.) It happens.

That said, check your records. You may have paid it initally at or near the time of service. I would think that would be the case because of the wording of the letter: "...and have determined that an additional payment is not available."

Your best bet is to contact your insurance company and ask them to explain the letter to you. Since you have not recieved a bill from the provider yet, don't jump that bridge yet. They may have been trying to squeeze more money out of the insurance company - sometimes, it gets caught that providers are underpaid, in "error" (I don't think insurance companies underpay by mistake!) and then the internal audit happens - and everyone who has this specific insurance who was seen during this period of time, has the claims reviewed to make sure there was no underpaying.

Speaking from my professional point of view, as to what I would do: Since it was two years ago, I'd be hard pressed to bill a patient, unless it was the first time I got something back from the plan. (It does happen, and when it does, I can prove it in writing to the patient when I bill them) IF you get a bill from the provider, call and ask them to double check their system to make sure you haven't already paid it. Technically, they really can't write it off if the insurance tells them to bill you for it - that's considered discrimination under HIPAA (by way of "favoritism"). BUT, they might anyway if you're reasonable to them. (Once the words "IT'S NOT RIGHT" come outta your mouth or you raise your voice, plan to get out your checkbook. If you freak out on them, they'll be less inclined to cut you some slack.)

Good luck.

Answer 3

Take a look at your medical records - my guess is that you already paid the $105.96 back at the time of services.

It sounds like your medical provider requested a review of the claim by your insurance company - perhaps the provider did an audit and felt that the insurer underpaid them according to their contract. (hence the "additional information received" comment - the provider most likely submitted additional info to the insurer trying to justify getting more money from the insurer)

When a claim is reviewed, the insurer has to send you notice too. That notice still has to dictate your total responsibility for your portion of the claim. More likely than not, you were billed $105.96 2 years ago and paid it.

In that case, the notice from your insurer doesn't mean that you owe an *additional* $105.96. It just means that the $105.96 you were originally billed still stands as a valid amount after reviewing the claim.

You should be able to clarify this with a quick call to your insurer. I've had to explain those letters to dozens upon dozens of customers for an insurer I used to work for, and never once did I see an instance where the patient actually owed additional money. Letters like that are worded in a confusing manner, but your insurer should be able to explain it more clearly over the phone. (And I wouldn't be surprised one bit if what they tell you is something very similar to what I described above.)

Answer 4

I would call your provider and when you get done with that, call the insurance and ask them what is going on. Usually there is a 60 or 90 day filing deadline for the provider. The only reason you should owe ANY money is because it was cosmetic and not something necessary. Otherwise, both parties need to have their story straight and you need to make sure and make them communicate with each other.

Answer 5

They can do about anything they want because most people won't question it. Call the insurance co and demand answers.

When you go to the doctor or hospital they ask you to fill out financial responsibility papers. YOU ARE SIGNING A BLANK CHECK. Write on the paper that you are not responsible for charges above insurance payments unless approved in advance, in writing.

Answer 6

Yes, you have to pay it.

Find out WHY it was adjusted. What was your responsibility before the adjustment? Did your responsibility go up or down? Call the provider, and ask why it took them 2 years...