by shortspark » Thu Dec 13, 2007 12:21 pm
Hello, just like everyone else I have been looking to the internet to try to find a solution to an insurance problem. I've done a search here but can not find a similar case so perhaps the best thing to do is lay it all out. Thanks in advance for any tips or experiences you may have.
My fiance's mother spent a long time in a nursing home before she died in March 2006. Medicare sent the patient a summary indicating benefits would expire (I think it has a 100 day limit) in a certain number of days from the date of the summary. Accordingly, the nursing home did not bill Medicare after the benefits expired and the patient paid the bill (a little more than $7000).
United Healthcare is the secondary insurer but refuses to consider the $7000 claim because, they contend, they are responsible only for charges not paid by Medicare and there is nothing in file to show Medicare denied the charges. We told them the nursing home did not bill Medicare after they notified them benefits would expire after a certain date, therefore, there is nothing from Medicare on the specific dates of the claim. UHC insists that it must have a rejection from Medicare.
We contend a rejection can not be obtained because the nursing home is not going to bill Medicare for charges that do not exist (they were satisfied by the patient). We are thinking of going to Small Claims but wonder if we have a chance. Does anyone have any advice?
My fiance's mother spent a long time in a nursing home before she died in March 2006. Medicare sent the patient a summary indicating benefits would expire (I think it has a 100 day limit) in a certain number of days from the date of the summary. Accordingly, the nursing home did not bill Medicare after the benefits expired and the patient paid the bill (a little more than $7000).
United Healthcare is the secondary insurer but refuses to consider the $7000 claim because, they contend, they are responsible only for charges not paid by Medicare and there is nothing in file to show Medicare denied the charges. We told them the nursing home did not bill Medicare after they notified them benefits would expire after a certain date, therefore, there is nothing from Medicare on the specific dates of the claim. UHC insists that it must have a rejection from Medicare.
We contend a rejection can not be obtained because the nursing home is not going to bill Medicare for charges that do not exist (they were satisfied by the patient). We are thinking of going to Small Claims but wonder if we have a chance. Does anyone have any advice?
Posted: Thu Dec 13, 2007 03:53 pm Post Subject: Can't get insurance co. to consider claim (Medicare related)
Hi shortspark,
Medicare sent the patient a summary indicating benefits would expire (I think it has a 100 day limit) in a certain number of days from the date of the summary.
I am just assuming that since Medicare is managed by the Federal Government, all terms and conditions are the same everywhere.
Traditional Medicare only pays up to 100 days in a skilled nursing facility.
Starting day 101, the patient is responsible for 100% of charges.
Since Medicare Supplement or "Medigap" policies were designed to supplement Medicare, these plans normally only pay on the charges approved by Medicare. If Medicare doesn't pay, the supplement doesn't pay.
As far as Small Claims, I certainly cannot advise you on that, but unless there is some very unusual circumstance, I really can't see where that would help.
Posted: Thu Dec 13, 2007 07:58 pm Post Subject:
Yes, that seems to be the case for the Medigap policy. I can see where the insurance company would not pay unless they have something in file saying Medicare did not. They are, after all, only a supplement to Medicare.
It appears our recourse may be with the nursing home instead. However, I just don't know how we can prove they were negligent in not billing Medicare even though the patient paid. They told us today that their policy is to bill the patient and no one else when the 100 days of Medicare nursing benefits run out. I believe they should have billed Medicare anyway, indicating on the bill that the patient paid, so that Medicare would deny the claim due to the 100 day benefit expiration. That would have been noted on the Summary Notice they send out and that is what the secondary insurer needs. I think many health providers do this but this nursing home does not or so they say. If they are not required to bill Medicare just for a denial it may be our case is out of luck.
Posted: Sat Dec 15, 2007 07:25 am Post Subject:
Check again with the nursing home. Explain your situation and ask again if they will bill Medicare. If they will not, ask for a breakdown copy of the bill that the patient paid. Contact Medicare and and see how you can submit it to them. You then should be able to get a denial from Medicare to proceed.
Posted: Mon Dec 17, 2007 01:39 pm Post Subject:
Thanks Dasfuk. I contacted the nursing home and they have their money so will do nothing. The business manager said she would call the main office but she won't. I will get a bill and see if I can submit it to Medicare directly as you suggest.
Posted: Sun Dec 19, 2010 02:39 am Post Subject: medicare not paying dr
i got letter from dr stating payment due. insurance info invalid.been on medicare 2 yrs and been using same dr
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