Insurance verified, active, but it’s the wrong insurance

Insurance verified, active, but it’s the wrong insurance

A family had a health insurance plan. Mom, dad and a couple kids. We will call this health plan ‘HCG’

One adult gets scheduled for a recurring service. Usually this is an injection that can’t be done at home, it has to have a healthcare person, in a safe setting, to administer it. We are going to call this person the ‘Patient’.

Patient and spouse have this insurance for the first 6 months of the year. Patient comes in once a month for this injection.

For January Patient has HCG insurance. Also has HCG for the months of February, March and April.

In May patient gets new insurance through an employer. Now patient has a new insurance called EMPH (employer health plan)

But because of a glitch, HCG still shows active for Patient.

In June the patient is scheduled for a visit. The verifier (that would be me) runs an eligibility on HCG insurance. It comes back as verified. Run authorization requirements and the injection needs and authorization, but there is one in place and good until July. I say that everything checks out. The patient checks in for the June appointment and has the injection.

In July the patient is scheduled for a visit. The verifier (again me) runs an eligibility check and the HCG comes back as verified. And the authorization is good until July 19th and Patients appointment is on July 12th. All good still.

On July 12th Patient checks in and hands the person who checks them in a new insurance card.

The registration team sends an SOS !!! email and ask me to review.

The HCG insurance still shows active. But now I can see the EMPH insurance I didn’t know about is also active. It (EMPH Insurance) also requires authorization, and no we don’t have one for this visit. Come to find out, the last visit was also supposed to be under EMPH and not HCG. And we had no authorization for that service either.

The registration people hand the phone to the patient and I get the story.

Patient got the new health insurance and instead of canceling patient at HCG, they canceled spouse. Patient says this is all worked out and the HCG insurance is aware. But this doesn’t help me right now or the patient right now standing on the desk on the phone with me unable to get their injection like they thought.

So, what happens. Patient can take their chances that the insurance would retroactive the authorization, which I personally would not recommend. And to do that they would have to sign a wavier that they would be responsible if the insurance company didn’t pay. I have seen drugs that cost $100,000 an injection uncontracted/self-pay value.

Or wait for an authorization if it won’t do harm to the patient. That is between you and your doctor.

If you have a regular visit like this. Or having something scheduled like a colonoscopy where you don’t want to know the evening before that there is an issue with your insurance (and your spouse will have to answer the phone and relay all this to you cause you just drank your colon prep juice and are in the bathroom for the next 4 hours making extreme advances on your phone app of candy crush), try to give the hospital or provider at least 2 weeks lead time to make sure they have updated information.

I personally would go into the hospital, find a registration desk where there were no people in line and just have them update my information and scan my card. The doctors offices may have your card, but it may not have made it to the facility records.  

The doctors call the schedulers with the order and mention the insurance. But in a lot of cases, we need all the card information to figure out the higher-level stuff regarding authorization for services. I can’t schedule a person in the system. I specialize in insurance. The scheduler has a different role. Need your left big toe amputated, they put the original order in - let them concentrate on making sure the services scheduled are for left toe and not right toe.  

The stuff I talk about, are real things that have happened. Every week there are a couple new things that come up that I learn. I technically am experienced and know what I am doing and this stuff is hard.

If you have changes in insurance, let people know. This person that I am referencing had a lot of other things come up with this change that the patient now has to deal with, even outside the hospital. But the person knew for almost 2 months there was an issue and waited until the appointment to bring it up. I felt sorry for the patient, but there was nothing I could do.

No one was at fault in my opinion. It was a mess. No one who doesn’t work in this stuff would think about all the stuff behind the scenes and how it could go wrong. That’s why I share some of these weird outliers. To get you to question your own unique situation and maybe avoid some of the pitfalls I have shared in various ways in these blog posts.