We had been submitting therapy claims for our eldest child for over two years, receiving partial to full reimbursement depending on the state of our family deductible. The provider has been out of network. We were receiving full reimbursement in 2021 after we met the deductible in May (birth of a child). Around October 2021, money got tight and we realized we hadn’t received reimbursement for July, August or September services. Something similar had happened in 2020, which we called and learned our insurance provider had started requiring an additional code (a GN code) to be submitted along with everything else for our claims. We did that and received reimbursement for those 2020 claims after doing this. Overall, we’ve received some sort of reimbursement or at least had the claim applied to our deductible since 2019.
Thinking some other type of change may have happened, I called our insurance provider. The woman I spoke to was clearly frazzled and working from home, which I can get, but it turned into an almost two hour long conversation (often because she would put me on hold for 15 minutes at a time to check something). She said those claims had been denied. When asked why, she said we didn’t give her the provider’s license #. We did, as it was the same documentation we’d been using since 2020 — I referred to it, which she acknowledged and found. She then said we didn’t give her the provider’s tax identification #, which I also referenced and said was on the same documentation. This employee literally said, “No, that’s the EIN. We need the tax identification #.” Uh…
After getting all of that walked through for her, she reveals that different employees had been using “dummy pins” to submit the claims, and that some 2021 claims (despite all having the same documentation issued every time) had been run with different pins that either put the claims towards our deductible or even *denied* them (which I hadn’t realized, because we didn’t receive any notice of this and assumed it was all just going to the deductible we knew we’d meet in the spring with our youngest’s birth) or, in the case of our May and June 2021 claims, fully reimbursed. She then “reran” the May claim on the phone with me and said we owed money.
Obviously frustrated and furious, I asked to speak to a higher up, and she flat out said, “No.” I pressed further, and she said she’d submit our claim to the manager and receive a call within 72 hours to discuss. We never heard back.
We’ve now received our second letter asking for the $225 to be paid back or be sent to collections. The first letter came right at Christmas when money was even tighter and we all got slammed with illness which almost put our youngest in the hospital. I hoped it would be ignored but had started to draft a response letter and do my research on Michigan health insurance bad faith law and then forgot about it until we got the second notice today.
I have a letter drafted, and it’s citing Michigan’s INSURANCE CODE OF 1956, Act 218 of 1956, but I’m assuming I’m too mom brained to really process this — and it makes both my husband and I nervous to potentially threaten legal action against a big health insurance conglomerate. Our ultimate goal is to not pay the $225 from May 2021 reimbursement they are asking back, but we’re out the $900 still from 2021 that they didn’t pay which we were expecting for July-September 2021.
Advice?
submitted by /u/firstsip
[link] [comments]We had been submitting therapy claims for our eldest child for over two years, receiving partial to full reimbursement depending on the state of our family deductible. The provider has been out of network. We were receiving full reimbursement in 2021 after we met the deductible in May (birth of a child). Around October 2021, money got tight and we realized we hadn’t received reimbursement for July, August or September services. Something similar had happened in 2020, which we called and learned our insurance provider had started requiring an additional code (a GN code) to be submitted along with everything else for our claims. We did that and received reimbursement for those 2020 claims after doing this. Overall, we’ve received some sort of reimbursement or at least had the claim applied to our deductible since 2019. Thinking some other type of change may have happened, I called our insurance provider. The woman I spoke to was clearly frazzled and working from home, which I can get, but it turned into an almost two hour long conversation (often because she would put me on hold for 15 minutes at a time to check something). She said those claims had been denied. When asked why, she said we didn’t give her the provider’s license #. We did, as it was the same documentation we’d been using since 2020 — I referred to it, which she acknowledged and found. She then said we didn’t give her the provider’s tax identification #, which I also referenced and said was on the same documentation. This employee literally said, “No, that’s the EIN. We need the tax identification #.” Uh… After getting all of that walked through for her, she reveals that different employees had been using “dummy pins” to submit the claims, and that some 2021 claims (despite all having the same documentation issued every time) had been run with different pins that either put the claims towards our deductible or even *denied* them (which I hadn’t realized, because we didn’t receive any notice of this and assumed it was all just going to the deductible we knew we’d meet in the spring with our youngest’s birth) or, in the case of our May and June 2021 claims, fully reimbursed. She then “reran” the May claim on the phone with me and said we owed money. Obviously frustrated and furious, I asked to speak to a higher up, and she flat out said, “No.” I pressed further, and she said she’d submit our claim to the manager and receive a call within 72 hours to discuss. We never heard back. We’ve now received our second letter asking for the $225 to be paid back or be sent to collections. The first letter came right at Christmas when money was even tighter and we all got slammed with illness which almost put our youngest in the hospital. I hoped it would be ignored but had started to draft a response letter and do my research on Michigan health insurance bad faith law and then forgot about it until we got the second notice today. I have a letter drafted, and it’s citing Michigan’s INSURANCE CODE OF 1956, Act 218 of 1956, but I’m assuming I’m too mom brained to really process this — and it makes both my husband and I nervous to potentially threaten legal action against a big health insurance conglomerate. Our ultimate goal is to not pay the $225 from May 2021 reimbursement they are asking back, but we’re out the $900 still from 2021 that they didn’t pay which we were expecting for July-September 2021. Advice? submitted by /u/firstsip [link] [comments]Read Morer/HealthInsurance