by Guest » Thu Dec 23, 2010 07:57 pm
Hi, If anyone can help on this below mentioned issue, it will be really nice.
underpaid claims
Insurance is not sending the claims for reprocess as the time limit for any dispute is 180 days. When told the rep that this was the error of the insurance that has not paid as per the contract, they said no matter whose fault it is, for any claims dispute the time limit is 180 days and we have already passed the time limit, so they are not sending the claim for review.
So is there any possibility to get the additional payment from insurance.
Please let me know.
Thanks
underpaid claims
Insurance is not sending the claims for reprocess as the time limit for any dispute is 180 days. When told the rep that this was the error of the insurance that has not paid as per the contract, they said no matter whose fault it is, for any claims dispute the time limit is 180 days and we have already passed the time limit, so they are not sending the claim for review.
So is there any possibility to get the additional payment from insurance.
Please let me know.
Thanks
Posted: Mon Dec 27, 2010 06:33 am Post Subject:
for any claims dispute the time limit is 180 days
Unless you're talking strictly about the time to file for the "holdback" ("replacement cost") on a homeowner's claim, it is unlikely that there is a 180 day limit on disputing a claim. In an HO policy, there is generally a 180-day period for filing any additional proof of loss to obtain the "holdback". Under normal circumstances, if there is a reasonable delay in completing repairs (for example, delays in obtaining planning dept approval, building permits, or inspections, or work stoppage due to weather), the 180-day period will be extended by mutual agreement.
Most states have a 1 or 2 year (or longer) statute of limitations when it comes to filing a legal action against an insurance company or an at-fault party in a claims dispute. So 180 days is unreasonable.
A little more information about the nature of the claim would be helpful. In what state did the claim occur?
Posted: Sat Jan 01, 2011 12:46 pm Post Subject:
Most states have a 1 or 2 year (or longer) statute of limitations when it comes to filing a legal action against an insurance company or an at-fault party in a claims dispute.
ampminsure.org/start/about15093.html
Posted: Mon Jan 10, 2011 03:08 pm Post Subject: Underpayments
It happens mostly with Aetna Fl insurance, I have lot of 2009 claims which were underpaid. It's for Hospital claims billed on UB-04.
and if anyone can let me know what is the difference between self-funded plan and fully funded plan??
Posted: Tue Jan 11, 2011 05:53 pm Post Subject:
and if anyone can let me know what is the difference between self-funded plan and fully funded plan??
Actually your question is about self-funded and fully-insured. Both of these are employer-sponsored plans. The difference is huge.
A self-funded plan is subject to ERISA, which is regulated at the federal level in most respects, and generally prevents certain (or most) claims against/claims denials by the plan from being taken to state court for adjudication (most actions must be taken to federal court, which is more costly, and perhaps less likely to occur, and where the available causes of action, and particularly the remedies, are generally more limited). A fully-insured plan, on the other hand, is regulated under and subject to state law, and claims may be taken to the state courts for adjudication.
A self-funded plan may "appear" to be fully insured because it is being "administered" by a health insurance company, but the insurance company actually has no direct responsibility for the claims in that situation -- as a TPA (Third Party Administrator), they are merely writing checks for covered claims and managing various other aspects of the plan. When the plan is actually fully-insured, then the insurance company has direct liability for the claims and my be sued if it fails to honor its contractual obligations.
This can also apply to employer-sponsored life insurance plans, but most employers will not "self-fund" group life insurance plans because the cost of insurance premiums is so much lower than the potential claims exposure compared to the cost of health insurance premiums and the actual claims experience of the plan sponsor.
Posted: Thu Jan 13, 2011 09:33 pm Post Subject: Underpayments
Oh.. thanks for the difference.
Is it correct that for self-insured plan the reonsideration of claims when it is underpaid is 4 years as per ERISA statute for all the insurance compnys expect for MEDICARE and MEDICAID?
Will the insurance company reprocess underpaid claims older than 2yrs when patient is self-insured?
Posted: Fri Jan 14, 2011 09:04 pm Post Subject:
Self-funded plans are governed under ERISA and its statutes of limitation apply to claims and payments.
Claims reconsiderations for fully-insured plans are governed under state law and the statute of limitations varies from state to state. In California, for example, there is a two-year time limit to file a legal action against an insurance company. (There is an absolute limit of one year to file "proof of loss" for any claim.)
However, if a company has engaged in a pattern of underpayments there may be additional action that the state can take against the insurance company for violations of state law that result in the underpayments being made up. This has happened recently in California with more than one insurer.
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