Priv. Health Ins trying to Collect for prev denied claim! (C

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Priv. Health Ins trying to Collect for prev denied claim! (C

Postby spreare on Wed Apr 08, 2009 9:45 pm

Our office is being bullied from Blue Shield (BS, no pun intended): Patient's work injury ( Employer Kaiser) originally denied and therefore BS agreed to reimburse medical costs, due to WC (kaiser) denial. BS orignally tells insured that if WC denies, they will cover medical. Dr. therefore bills BS and they reimburse. Later, WC accepts injury, and BS gets wind of this, demands payment back from Dr. -- demanding we pay them back, and get money from kaiser to do so. BS C.C. WC carrier in their demand, but they don't demand kaiser pay, they demand Dr pays! (how is the dr. the responsible party????) I, the Dr., find this collection attempt against our office inappropriate in that we acted faithfully in being informed that WC denied and that it was therefore appropriate to bill BS for needed treatment. It seems like BS needs to subrogate from Kaiser, and I am dumbfounded they are trying to collect from us, but maybe there is some insurance principle I am unaware of? Please help. not sure what material exists to guide us on this.
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Re: Priv. Health Ins trying to Collect for prev denied claim! (C

Postby on Thu Apr 09, 2009 4:38 am


I had not heard of this practice by "BS" until a couple of months ago....after 30+ years in the business.

It has something to do with the arrangement or contract BS has with medical providers. Bottom line is I saw a hotly contested heart surgery case (non-presumptive) where BC had paid over %50k just to a hospital. There were other payments to individual doctors, pharmacies, etc., totaling another $25k or so.

Bottom line is BS asked for its money back after a cardiology AME concluded PART of the heart problem was caused or aggravated by employment, but not the entire problem. Some of the heart surgery was based on a pre-existing problem, totally unrelated to the portion which was industrial and which needed treatement separately.

BS asked for their money back from all medicl providers except the hospital. There they simply took it back, how I don't know! The money apparently is paid into an account by them for the use of the hospital and when they think they are entitled to a refund, they take back what they want. (Talk about 800 lb gorillas!)

The other providers were required to reimburse the money ASAP and all did!

Meanwhile, med-legal exams are pending to help separate out what is and is not industrially related. Eventually, BS will probably owe something around 50% and the w/c carrier, the rest.

The BS coverage in question has lapsed. Allmost all payments have been refunded. The EE has naturally been asked to make some reimbursements on payments of self-procured. I doubt this has happened. My suggestion was to tell them to "Wish in one hand.....!"

Presumably BS can provide you with copies of their contract with medical providers which allows them to do these things!

Good Luck!
Stew (James T. Stewart)
Author: Work Comp Index, 7th ed., 912 pgs; next ed. summer, 2010.
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Tables & Schedules in "The Labor Code Book," by LexisNexis/Matthew Bender
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Re: Priv. Health Ins trying to Collect for prev denied claim! (C

Postby rider001 on Thu Apr 09, 2009 8:16 am

I had a simular situation happen when working for an ortho about 2 years ago. I told BS that i would go ahead and rebill the comp carrier and when i recieved payment from them i would reimburse them. BS followed up every month untill payment was secured from the comp carrier. If you don't pay or don't respond they will take the money from other patients accounts. Happens all of the time. BS thinks it made a payment in error they give very little time to research and respond before they start taking money. That becomes a posting nightmare.
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Re: Priv. Health Ins trying to Collect for prev denied claim! (C

Postby rosellavera on Thu Apr 09, 2009 8:35 am

Am I missing something here? Why doesn't BS file a lien? Rebill the comp carrier? I would think that BS would be entitled to reimbursement from comp carrier now that the case is accepted. Send BS a letter requesting that they do the above. Should work. BS has a work comp section. Talk to someone in that dept.

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