Tag Archives: Insurance

Coordination of Benefits and Massachusetts Insurance Regulations

11 Apr

If, like me, you have two or more health insurance policies, the order in which the policies pay is determined through a process called coordination of benefits, which in Massachusetts is governed by regulation 211 CMR 38.00 [pdf].

In my case, it gets a little bit complicated because my two policies are from different states. I haven’t looked at California coordination of benefits regulations, but if they differed significantly from the Massachusetts policy it would be possible to have a situation in which neither plan (or both plans) were obligated by their respective state laws to pay as the primary insurer. For now, though, I’m just going to look at the Massachusetts regulation.

A number of my providers incorrectly billed my UC Berkeley Student Health Insurance Plan (SHIP) first. My oral surgeon’s billing person even tried to tell me that I was wrong when I insisted that my parents’ policy should have been billed as the primary insurance. At a glance, it might seem that she is right (211 CMR 38.05):

(3) The benefits of the plan which covers the person as an employee, member or subscriber (that is, other than as a dependent) are determined before those of the plan which covers the person as a dependent.

I’m not exactly covered by my Blue Cross Blue Shield as a dependent but as a former dependent, since the Massachusetts insurance reform allows young people to keep their parents’ insurance for two years after loss of dependency or until age 26 (whichever is first). Still, I’m definitely the subscriber for my SHIP coverage, so it would be tempting to say that this means that my student plan is primary.

However, turning to the definitions section of the regulation (38.03), we find the following (emphasis mine):

Plan: a form of coverage with which coordination is allowed. The definition of plan in the group contract must state the types of coverage which will be considered in applying the COB provision of that contract.


Plan shall not include:
(a) nongroup coverage except for coverage described in 211 CMR 38.03: Plan(d) through (f) above, or when a nongroup plan chooses to coordinate with other nongroup plans;
(b) Medicare or other governmental benefits except to the extent permitted by law;
(c) student accident coverages, Qualifying Student Health Insurance Programs (“QSHIPs”) or other student health plans when designated as “excess only” or “always secondary plan”;
and
(d) a plan under Medicaid, or any other plan when, by law, its benefits are secondary to or in excess of those of any private insurance plan or other nongovernmental plan.

In other words, the coordination of benefits regulations don’t apply to student insurance plans, so long as those plans specifically designate that they are secondary to other coverage (as SHIP does). When the regulation refers to “the plan which covers the person as an employee, member or subscriber,” my coverage under SHIP is not included, because SHIP–although it covers me as a subscriber–is not included in the word “plan.”

It’s easy to see where providers would get this wrong. When I filled out paperwork, I had to specify the name of the policyholder, but I never had to indicate whether the policy was a student health plan. From the information they had, was reasonable (but incorrect) to guess that my SHIP plan was primary.

The coordination of benefits regulations don’t just determine which insurance company has to pay first. They also determine how the benefits are calculated. This brings me to the point that I found myself repeating over the phone with BCBS on Friday (38.05):

(1) The primary plan must pay or provide its benefits as if the secondary plan or plans did not exist. A plan that does not include a coordination of benefits provision may not take the benefits of another plan into account when it determines its benefits. There is one exception: a contract holder’s coverage that is designed to supplement a part of a basic package of benefits may provide that the supplementary coverage shall be excess to any other parts of the plan provided by the contract holder.

The one exception doesn’t seem to apply here, so the regulation requires that BCBS pay its benefits as if there are no secondary plans. That might seem to imply that they can’t take into consideration the fact that another plan has paid benefits (even if that plan was billed incorrectly), since a plan that doesn’t exist certainly doesn’t pay benefits.

However, there is something of a loophole here. As quoted above, the regulation doesn’t state that student plans are secondary plans. It says that, for the purpose of coordination of benefits, they should not be considered plans at all. Thus, BCBS could argue that they aren’t prohibited from taking the existence of my SHIP coverage into consideration because SHIP isn’t included when the word “plan” is used in this paragraph. Such an interpretation would seem to be contrary to the spirit of the regulation, but it may well be consistent with the letter of the law. I hadn’t thought of this when I was on the phone with BCBS, so I guess I’m just lucky that she didn’t know the law and considered it irrelevant.

Progress

10 Apr

This week marked a year since my accident. I had intended to mark the occasion with a Sunday visit to the site of the accident, hoping to find the pavement in a newly-repaired state. Alas, the weather was uncooperative. I had little interest in going out in the rain, particularly when the destination was a patch of pavement which I had the best of reasons to believe was unsafe even when dry. Thus, I had to settle for the next best thing: spending a lot of time on the phone with insurance company representatives trying to convince them to pay the bills I had incurred a year earlier.

To review, here is my insurance situation. I have dual coverage. As a UC Berkeley graduate student, I’m covered by the UC Berkeley Student Health Insurance Plan (SHIP), and because my parents live in Massachusetts, their (more comprehensive) plan also covers me. The latter plan is primary except for on-campus services. If that sounds confusing, you’re in good company, as there’s been considerable confusion among the providers and the insurance companies. Several providers, most notably my oral surgeon, incorrectly billed SHIP first.

By now, most of the confusion with the bills seems to have been ironed out, but the oral surgeon’s bill has been a bit problematic. A large bit of the trouble is that the oral surgeon was out of network for both of my insurances, and so there’s just a larger expense to be paid than for the other bills. SHIP paid a little less than half of the roughly $3700, and then the remainder was sent to Blue Cross/Blue Shield of Massachusetts (BCBS). I didn’t hear anything until late fall, when my father told me that he received something from his insurance saying they had rejected the claim. I didn’t do anything about it until January when the oral surgeon’s office called me looking for money.

At this point I called the BCBS member service number to ask why they had denied the claim. I was told that my other insurance had already paid it in full. I objected to the use of the term “in full”, having just received a bill for the $1963 that hadn’t been paid. The representative clarified that this just meant that the other insurance had already paid more than they would have paid.

I didn’t really believe this because I was pretty sure that my BCBS insurance was better than my SHIP insurance. Of course, I don’t really know how  they calculate benefits (and, it turns out, very few people do), so I brought up the one point on which I knew something was wrong. I told them that they should have been billed as the primary insurance. Once the rep got over the confusion, I was connected to the Coordination of Benefits department. The woman on the phone explained that my claim had been denied simply because they saw there was a payment from another insurer and they didn’t know anything about that insurance. I didn’t understand the reasoning behind this, and it didn’t make sense to me that they should deny the claim instead of asking me for information, but I did give them the information for my other insurance. I was told that it should take 30-45 days to work out the coordination of benefits with my other insurer and that afterwards they would automatically reprocess the claims they had denied.

In mid-February, the oral surgeon’s billing person called again.  She seemed very skeptical that BCBS would pay anything, but in any case, she needed me to pay something then. I authorized a charge of $500. (It is perhaps worth mentioning that this wasn’t the same billing person who called me a mere two hours after my surgery and expressed her frustration at my inability to clearly communicate my insurance information.)

About 30 days after my first call, I called BCBS to see how things were going. I was informed that it would actually take 30-45 business days. However, my call wasn’t a complete waste as it turned out that they had a question for me. They needed to know the claims address for my SHIP insurance, so I gave that to them.

A couple weeks later–31 days from my first call–I called again. I was put on hold for a few minutes before being told that somebody was calling my other insurance company that very minute. It was kind of a stunning admission, really. Here I had been told that something would take 30-45 business days, but they seemed to only begin when I called to remind them that it had 30 days.

I called again the following week to see whether they had actually come to a conclusion. It turned out that they had correctly determined that they were primary for off-campus services and secondary for on-campus services. However, they had incorrectly decided that my oral surgery was on on-campus service and denied the claim again. I corrected them on this, and fortunately, they were willing to believe me without taking 30-45 business days to investigate. I was told that my claims was being sent for adjustment.

Some time around the middle of March, I received another bill from the oral surgeon. I was a bit tired of dealing with them, and I felt bad about making them wait for payment, so I just decided to pay it in full and hope to get money back later.

Perhaps unsurprisingly, at the beginning of this week, I hadn’t heard anything, so I decided to call BCBS on Tuesday. This time, I called the member service number because it had seemed as though Coordination of Benefits was done with me. The guy on the phone, however, put me on hold so that he could talk to somebody in Coordination of Benefits. He assured me that they had indeed resolved the situation with my SHIP insurance. However, the claim had been flagged as being related to an accident, and so they had decided that they needed to look into whether there were any other insurance companies that might have to pay before them. I did tell the guy that the cycling club I was with had a policy that would pay after my primary health insurance. I was glad he didn’t ask for more information than that because I didn’t have the information with me. By this point, I had already been on hold several times, and he put me on hold again for a few minutes. When he came back, he told me that the problem was that there was a payment from my other insurance. I emphasized that as the primary insurer, they were required to determine benefits without reference to any other insurance. He told me they would deal with the issue and adjust the claim. I asked if there was a timeframe on that, and he answered in the negative. When I told him I’d have to call every day until they had some progress to report, he suggested I wait 30 days before calling again.

I didn’t want to wait 30 days, so I called Coordination of Benefits today. This time, the rep explained that because there was a payment from another insurer, they couldn’t issue a payment as the primary insurer. I pointed out that under Massachusetts state law, as the primary insurer, they could not legally take the existence of another plan into consideration when determining benefits. She said that they would be happy to pay as the primary insurer after SHIP retracted their payment but that they couldn’t issue a payment sooner because otherwise the provider would receive double payment. I wasn’t satisfied with this answer. It didn’t make sense that they should insist that SHIP get their money back before they paid; if BCBS really cares it should be enough that SHIP get their money in the first place. She didn’t budge on this, though. I also asked if, when she said that BCBS “can’t” issue a payment until SHIP retracts its payment she was referring to a BCBS policy or a law, and if it was the former whether she knew it to be consistent with Massachusetts law. She told me she didn’t know about the law, adding “I don’t understand why you keep bringing that up” as though the law were completely irrelevant because they didn’t have to follow it. She said that it was their policy and that no other insurance company would issue a payment under such a circumstance, either. This, of course, says nothing about legality (more on that later). I asked if, rather than waiting for SHIP to retract their payment, BCBS could send a payment to SHIP. She told me that they could not.

Then things got interesting. She asked me whether I had received a bill. I explained that, in fact, I had already paid everything that SHIP had not. She explained that the provider couldn’t do that to me because they had already been paid the full amount that they were guaranteed under their contract with BCBS. I told her that the provider wasn’t in network (a fact I would have expected her to know), and suddenly I was on hold again.

When I’m having this kind of conversation, I actually really like being put on hold. I like having a few minutes to organize my thoughts and plan what I’m going to say. In this case, I planned to explain to her that I was uncomfortable with the idea of asking SHIP to retract their payment because the oral surgeon’s billing person had already run out of patience for me, and I didn’t want to get stuck with a big bill while BCBS continued to take their time making a payment.

When she came back, I was pleasantly surprised to find my prepared statement unnecessary. She told me that because my provider was out of state, it was being processed by the Blue Card network, and that they would be submitting my claims to Blue Card to be paid as primary with instructions to return the payment from SHIP.  She told me that my obligation would be a $250 deductible plus 20% co-insurance (capped at $1000), which works out to about half of what I’ve already paid. This part of the conversation was polite on both ends, with no signs of the mutual irritation that pervaded the first segment of the conversation.

I’d love to know what happened to change things in the few minutes that I was on hold.

When I started this post, I was planning on also writing about a couple of related topics: the relevant Massachusetts law and the question of whether the various statements from BCBS could possibly be considered consistent. However, this post is already pretty long, and it’s late, so those topics will have to be covered in additional posts in the next few days.

Bills

28 Feb

By the time fall came around, I had assumed that my insurance had paid all of my bills since I hadn’t received any more. It turns out that I was wrong; they were just very slow to reject a couple of claims. Specifically, my parents’ insurance has rejected claims from Berkeley Emergency Medical Group and the oral surgeon.

The balance with Berkeley Emergency Medical Group was only $76.30, but I haven’t gotten a bill from them yet. The oral surgeon’s bill is much bigger, nearly $2,000, because it was out-of-network for both of my insurances. The oral surgeon’s office also seems to be in a bigger hurry to get money from me. I’ve received a bill from them as well as a couple of phone calls.

The billing person at the oral surgeon’s office told me that my claim was rejected because of a non-duplication of benefits policy. However, when I called the insurance company, they seemed to be telling me that they had rejected my claim simply because they didn’t know anything about my other insurance and thus couldn’t determine how much they should pay. So I gave them the information for my other insurance, and they told me that they’d take 30-45 business days to figure things out and then process the claims again. That was about 26 business days ago, so I’ll call them again at the end of this week.

I also authorized a partial payment to the oral surgeon’s office, since I don’t want that balance turned over to a collections agency. The oral surgeon’s office seems thoroughly confused about this situation, and I really think they underestimate how much my insurance will owe. This is, after all, my primary insurance, but the oral surgeon’s office billed the other one first.

I’ve started to wonder why I was referred to this oral surgeon from the emergency room if it was out-of-network for my insurance. One possibility is that it was because the emergency room had my insurance information wrong, initially billing Blue Shield of California instead of any insurer with which I actually had a policy. Next time I talk to the oral surgeon, I’ll ask if they’re in network for Blue Shield of California. Of course, it’s also entirely possible that the emergency room just doesn’t have a policy of referring within network.

I’m a terrible blogger

23 Aug

I haven’t updated in way too long, but that’s largely because not much has changed. Here’s what has changed since my last update:

  • The feeling on the left side of my face is a little bit more normal. The occasional sharp pains have become less frequent. I don’t know whether I should expect this to get any better than it already is.
  • The tenderness around the site of the fracture has gone away.
  • Since the accident, I have experienced (but apparently have forgotten to write about) some pain in my left ear. I’ve generally assumed it was a result of swelling around the fracture. This hasn’t gone away completely, but it is a lot better than it was for a while.

As for billing, not much is going on. I paid my $25 bill from Alta Bates. I also received another copy of the bill from Berkeley Emergency Medical Group, and responded by sending them the information for the insurance that they had neglected to bill.

Fourteen week billing update

13 Jul

I haven’t received any billing-related mail in the last week, so this is something of a non-update. I don’t mind not receiving bills, of course, but this is not quite as good as learning that my insurance has paid the outstanding balances.

Thirteen week billing update

5 Jul

I’ve seen a little bit of action on the billing front this week.

  • When I posted my last update, I had just emailed my second insurance information to Berkeley Emergency Medical Group and Bay Imaging Consultants. The next morning, I received an email from Bay Imaging Consultants informing me that they had billed the second insurance. I have still heard nothing from Berkeley Emergency Medical Group.
  • I received a bill from Alta Bates Summit Medical Center for my treatment. The total amount was $1,944.10, but insurance adjustments decreased that by $505.45 and insurance payments knocked off an additional $1,413.65, leaving me to pay only $25. I plan on paying  this amount by credit card in a few weeks so that it will go on my August statement rather than July. I have the money in my account, but I might as well earn interest on it for another month.I also requested an itemized bill from Alta Bates by phone, and this arrived on Friday. I haven’t found it very helpful, though. It does have a charge of $16.72 for “ORAL/IBUPROFEN 600MG T”, which I’m not sure I received. It’s possible that it’s something they had me take some in the hospital (but sixteen dollars worth?), but I definitely didn’t take a bottle home with me. The doctor actually gave me a prescription for ibuprofen, but the pharmacist told me to just buy it over the counter. I don’t plan on looking into this because I don’t think it would affect the amount I pay after insurance.

    Incidentally, neither the original bill nor the itemized bill tells me which insurance paid, but I think it’s my father’s insurance because I did tell Alta Bates that his insurance was primary.

The accident revisited

4 Jul

I have to begin with a confession. When I wrote about my accident, I wasn’t entirely sure that everything I was saying was true. I didn’t say anything that I knew to be false, but I didn’t remember all of the details of how I had fallen. When I had no information about something, I didn’t say anything, but there were a couple of statements I made that were guesses based on what I did remember and what seemed to be the best information at the time.

For example, I wrote that I had been taking the downhill stretches faster than I was accustomed, and claimed that this was the cause of my accident. It’s true that I had taken some downhill stretches faster than I would have when riding alone, but I never had any specific recollection of going fast down the particular hill where the accident took place. When I stated that I had been going faster at the time of the accident, I was extrapolating based on what I did remember in a way that seemed to explain why I had fallen. Similarly, when I said that my bike crossed over the center line in the road, I didn’t have any specific recollection of that having happened at that particular turn. I had some recollection of it having happened somewhere, and it seemed reasonable to conclude that it was the place where I had crashed.

Anyway, I needed to make that confession because I revisited the scene of the accident this morning, and what I saw there led me to question both of the claims discussed in the preceding paragraph.

As I approached the turn where the accident took place, I could see that there were plenty of signs warning of a difficult turn. First was  something painted on the street by a well-meaning amateur.

SLOW!

Then there were the road signs as I approached the turns.

Right Turn, 15MPH
I’ve always been a careful cyclist, so this signage came as a surprise to me. I just couldn’t believe that I’d ignored it. The fact that I didn’t remember it being there  might suggest that I wasn’t paying close enough attention, but I also could easily have forgotten in my post-accident shock. (It also occurred to me that when the EMT asked how fast I had been going and eventually got me to agree that I had been going 20 to 30 miles per hour, I had admitted to breaking the speed limit.)

When I got to the actual turn, there were even more warnings.

Yellow Light, Right Arrow

I stopped at the corner to reflect on things and examine the scene for a while. Obviously, with the accident having happened 90 days earlier, there were no visible traces of my accident. However, one patch of pavement did catch my attention.

Cracked pavement

With the shade and an unfavorable angle, the photo doesn’t adequately display the magnitude of the hazard that this presents to bicyclists. In particular, it’s hard to see in the picture how deep some of the ridges were. Here’s another shot, which still doesn’t really do it justice, but it provides a little bit more information.

Another view of the cracked pavement

Also, the hill that preceded this turn actually did seem pretty steep, contrary to what I had thought when I looked at it on Google Street View.

Somewhat steep hill

In the hours since my return to the site, I’ve become increasingly convinced that the condition of the pavement played some role in my accident. The evidence is far from conclusive, but my biggest objection to that theory was easily resolved. This objection was that the cracked pavement was only found on the side where I was supposed to be riding, and I remembered crossing over the center line. As I mentioned previously, though, that memory of crossing the line may not be from this particular spot. Moreover, even if it is from that spot, it’s possible that I lost control on the broken pavement and then crossed over the line and fell.

I’ve spent a good amount of time examining my injuries and the scratches that the bike acquired in the accident, trying to figure out exactly how I fell and whether that might convey any information about the quality of the pavement I was on. The main way that such information might arise is if the bike were scratched in places that wouldn’t touch smooth pavement when I fell on it, but might have been able to touch pavement that was sufficiently uneven. Indeed, there are some scratches in places that seem like they shouldn’t have made contact with the road, but it’s not clear to me that the scratches could have come from falling on the ridged pavement either. The only other possibility seems to be that these scratches predated the accident (but I didn’t notice them until afterwards) or that they were acquired while the bike was at the fire station.

Since the morning, I’ve also had flashbacks of falling from my bike towards badly cracked pavement. I suspect that this isn’t an actual memory but something that my mind has fabricated to support my new theory of the cause of the accident.

Of course, all of this speculation on what happened that day has only minimal practical value. Determining the cause of the accident isn’t going to change the fact that it happened. Nor would it change the fact that the worst effects of the accident have, by all indications, passed. The only possible benefit from knowing why I fell would seem to be liability purposes, and not only does it seem unlikely that I’d be able to build a strong enough case, but I have no interest in pursuing litigation against a city that is broke when my insurance companies seem to have picked up most of the tab for my bills. I’d much rather see money go to fixing road hazards, which is why I reported this spot on the East Bay Bicycle Coalition’s hazard reporting site. Much to their credit, Oakland’s Public Works Agency apparently does a good job of fixing hazards quickly after they are reported, according to an article in the East Bay Express.

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