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I am this close to calling an attorney

skittles_123skittles_123 member
in Special Needs

We have had a private policy for my ds for about 18 months now. The first year or so of the policy, we had no problems. Quite the opposite of what we had experienced with other insurance companies in the past. I thought this was too good to last. And boy, was I right.

So I submit claims myself, as most of my providers (ABA), do not bill insurance. I have been doing this seamlessly since we started his policy, submit the claims by mail, get checks back reimbursing us the money we paid providers out of pocket within about 3 weeks. The checks stopped coming in Jan 2011. We expected a brief time of this because we had to meet our deductible for the new year, which took all of 3 weeks to meet. But, we also had claims/reimbursements that had not come back from the previous year.

Been talking to a lot of people at the insurance company and the autism case manager at insurance. Autism case manager tells me that started a new process of doing claims electronically versus by hand, and everything has gone haywire. He has our claims and sees them in the system. To get the EOB's and reimbursement checks, I needed to contact the main number on my card. Call them, they do not see any claims for ABA in their system. They are clueless. They do not know what is going on. So I send the claims directly to them per their request.

I get one EOB for one claim stating it was a duplicate. It was not and I told them this over the phone before I even sent it in. Then I get a bunch of nonsense in the mail saying that one of my providers is not found and they cannot process the claim. I call them last night on this, and they have no clue what is going on. They are going to do some research and get back with me today.

I am so fed up with this. Law says they have to reimburse us within 30 days or they pay 12 percent interest. I am going to push for this, but I just want our money, over 4 grand they owe us, we have no money right now, we are having to use credit cards, and I am this close to getting an attorney.

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Re: I am this close to calling an attorney

  • JenGKJenGK
    Don't even get me started on insurance.  I have to call them every month after they process and deny our OT claim, saying the provider is not in their service area and I need to submit to another branch of the company.  And every month when I call back, they put me on hold for 30 minutes plus, and then come back and say, "oops, sorry, but it will take another 30 days to reprocess and pay."  I'm tempted to start submitting maps with our claims.  But I do get interest from them on the delay claims, which makes me feel a little better.
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  • JaysonandKristinJaysonandKristin member

    You don't need an attorney to get the penalties you're owed.  They should have expected that delays like this were going to happen, and should have budgeted for the penalties and interest they would owe providers and policy holders during this transition period.

    Find out where you need to send your correspondence and get a certified letter into the insurance company as soon as you can claiming that you will enforce the 12% if reimbursement is not received by X date.

    I understand if hiring an atty is just easier for you, but I wanted to ensure you that you don't need to hire one to get your money.  The insurance company is required to issue that money to reimburse you and it's no surprise to them that any payment made outside the 30 day window is subject to penalty/interest.

    I used to work for an insurance company, and knew for the sake of litigation and for sake of internal/gov't audit I was to issue interest/penalty payments when I found they were appropriate or when someone called to let me know that they were warranted.

    Good luck!!  I just hope things go back to seamless soon.  When we transitioned to paperless systems 2 years ago, there was a lot of this for about 10 months.  It sucks, on both sides.   

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  • realisticdreamsrealisticdreams member

    How frustrating.  

    We've only had a couple of problems, although I've noticed they've been denying Peyton's at home PT through EI.  Her secondary picked it up and I honestly haven't had the energy to call and ask why.

    Like SN moms don't already have ENOUGH going on to have to waste more time on the phone.  

    I had no idea about the 12% interest, that's nice to know.

    Maybe in the future you can pay everything on credit cards, that way if they are slow you don't have to wait for 'real money'?   

    DD1(4):VSD & PFO (Closed!), Prenatal stroke, Mild CP, Delayed pyloric opening/reflux, Brachycephaly & Plagiocephaly, Sacral lipoma, Tethered spinal cord, Compound heterozygous MTHFR, Neurogenic bladder, Urinary retention & dyssynergia, incomplete emptying, enlarged Bladder with Poor Muscle Tone, EDS-Type 3. Mito-Disorder has been mentioned

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  • BeenThere22BeenThere22
    How frustrating!! I hope things work out soon. One thing I did when we were going through *** to get them to pay for G.'s stuff was to write down EVERY correspondance k had with them (phone etc). So when they gave me the bull crap line that I wasn't telling them about it, I whipped out my notepad and said BS, LOOK!
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  • LillyGrrlLillyGrrl member
    I might also suggest getting in touch with your State's Department of Insurance to lodge a complaint. Insurance companies have a limited window in which to respond to complaints.  You should have an answer within 10 days or so.
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