At the time of patient admission, the Provider called the Insurance Company to verify policy benefits. An insurance representative confirmed that coverage was currently in effect. The insurance representative also stated that the insurance policy provided 80% coverage of usual and customary charges for the schedules procedure, with a $500 deductible and a $100,000 maximum.
The charges were filed with the Insurance Company. The Provider received a claim denial stating the policy lapsed several weeks prior to the hospital admission.
The Provider appealed the denial based on the verification. The Insurer responded that coverage had lapsed due to nonpayment of the required insurance premium. The insurer also stated that each insurance representative reads a disclaimer to providers indicating that the benefits quoted are subject to change and are not guarantees of payment. The denial is upheld.
Federal and state courts have ruled that Insurers have the duty to pay according to the verification given at the time of patient admission. This determination is based on the court’s recognition that any verification of benefits acts as an inducement on the provider to treat the patient in return for a promise of payment. In such cases, Appeal Training will appeal with federal and local cases which most closely match the circumstances involved, including citing information given during precertification information and case management reviews, which can be seen as continued acts of inducement.
Insurance Company made payment within 30 days of receipt of verification of benefits appeal.
Potential application for Your Medical Facility:
A good verification of benefits is the first line of defense in seeking reimbursement from an Insurance Carrier. Appeal Training will assist your facility in making sure that the time spent on securing a good verification results in added revenue. A verification is also crucial in securing payment of services which are not recognized by the insurance industry as part of standard coverage, i.e. in vitro fertilization, high dose chemotherapy with autologous bone marrow transplant, and certain procedures often sometimes controversially deemed as cosmetic such as growth hormone therapy and jejun-ileostomy (stomach stapling).
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