Should I take my chances?

by Guest » Thu Apr 26, 2012 03:09 am
Guest

Here's the deal: I started a Blue Shield HMO with my previous employer from 9/1/2009. I left that employer on 9/1/2011, and I now work somewhere else; I've had an EPO with EBA&M since 10/1/2011.

On 12/19/11 and 1/13-1/14, I made several visits (family doctor, blood lab, etc), making sure that those places were in my EPO's network. To my horror, they called me yesterday and told me that since I didn't get a tracking number from EBA&M before I made my visits, they were NOT going to pay for my visits. Now I'm stuck with bills totaling over $2,000. No one told me about this tracking number.

Meanwhile, because EBA&M had asked for a HIPAA certificate from, I had to call Blue Shield so that EBA&M knew when my coverage with Blue Shield started and stopped. This was when I found out that I WAS STILL BEING COVERED BY BLUE SHIELD. I never applied for COBRA insurance, but as of today, I'm still covered by Blue Shield (even though I've never paid for COBRA). Maybe my previous employer made an oversight and are still paying for my insurance. I don't know.

Here's my question: I'm thinking of asking my doctors, labs, etc. to charge BLUE SHIELD since EBA&M won't pay for the bills. If Blue Shield is billed for all this, will they charge me COBRA premiums retroactively from October all the way to January? Or maybe even until now? If they do, there is no point for me to do this, since I'm guessing COBRA coverage is about $500 a month, and that will be about $2,000? Should I take that chance? Or does Blue Shield have no right to charge me the COBRA premiums since I never asked for them? Please advise. In the meantime, I'll be writing an appeal to EBA&M, but I don't think that's really gonna do anything.

Total Comments: 2

Posted: Sun Apr 29, 2012 02:29 pm Post Subject:

I'll be writing an appeal to EBA&M, but I don't think that's really gonna do anything.


While your "internal" appeal of an "adverse benefits decision" may not result in the outcome you desire, it is a necessary first step to preserve your rights under the Patient Protection and Affordable Care Act (PPACA). Following the denial of your appeal, you can demand an "external" appeal through the US Dept of Labor and the US Treasury (some of the plan's operation involves contact with the Internal Revenue Code, so the IRS becomes involved).

since I didn't get a tracking number from EBA&M before I made my visits, they were NOT going to pay for my visits. Now I'm stuck with bills totaling over $2,000. No one told me about this tracking number.


This is an insidious little provision that the PPO industry cooked up a number of years ago (EPOs are an off-shoot of PPOs) to avoid some of the higher claims expense when using non-network providers. They tell you something like, "To obtain the maximum benefit from your plan, please call us at 800-XXX-XXXX prior to obtaining services from your provider." And they use the failure to do that to charge higher copays and coinsurance.

There is probably a disclosure about the "tracking number" or some other kind of prenotification buried deep in all the paperwork you received (there should be something about this printed on your benefit card.

While failure to prenotify can cause you to pay a higher share of cost, it should never preclude coverage 100% for something that would otherwise be covered (and it would never apply to emergencies or urgent care in lieu of a trip to the ER). Your employer's health plan is probably "self-funded" (since EBA&M is a "Third-Party Administrator) and governed under ERISA, unless it is fully-insured, in which case it would be governed under state insurance laws.

Although you should go through the appeals process first, you can always file a complaint with the US Dept of Labor's Employee Benefits Security Administration (EBSA). Do that here: https://www.askebsa.dol.gov/WebIntake/Home.aspx

Because it is most likely governed under ERISA, your ability to sue your employer's health plan for damages is virtually nil. Using the EBSA to investigate the situation is your best course of action.

Meanwhile, because EBA&M had asked for a HIPAA certificate from, I had to call Blue Shield so that EBA&M knew when my coverage with Blue Shield started and stopped. This was when I found out that I WAS STILL BEING COVERED BY BLUE SHIELD. I never applied for COBRA insurance, but as of today, I'm still covered by Blue Shield (even though I've never paid for COBRA). Maybe my previous employer made an oversight and are still paying for my insurance. I don't know.


This makes no sense. But if premiums were paid, then I suppose you could submit a claim to Blue Shield. Unfortunately, if they discover the coverage error, your claim is likely to be denied, and the excess premiums credited back to your employer. (On the other hand, your employer may be voluntarily paying those premiums for you without your knowledge for whatever reason. You might call that employer's HR department to ask about the situation first.)

My inclination would be to suggest filing the internal appeal AND making the complaint to EBSA and forget about your former employer's coverage. If there is not adequate disclosure concerning preauthorization, EBSA will demand your claim be paid. They may also fine the Third-Party Administrator (EBA&M) and/or your employer. You cannot be sanctioned for filing a complaint.

Posted: Sun Apr 29, 2012 02:44 pm Post Subject:

You may find these articles from the EBSA helpful, too:

http://www.dol.gov/ebsa/newsroom/fsproposedm1revisions.html

http://www.dol.gov/ebsa/newsroom/fsproposedm1revisions.html

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