Substance abuse coverage claims with insurance companies and facility filing them.

Asked about 6 years ago - Western Springs, IL

I insured my daughter with humana following an addiction problem that needed in patient stay. Prior to adding her to my plan (which cost an additional $900/month) I spoke in depth w/Humana about coverage details and decided to bring her to a facility that was "in network" with Humana. The facility talked with both Aetna (her other coverage) and Humana and informed us that coverage would be 90% for "in patient" and that in order to acquire that we would need to pay an additonal $100/day for her to stay full time. We did so because the cost of care was significant. Humana was declared primary, and Aetna secondary. We waited hours there while details about coverage were taken care of . All we needed to do was to continue getting approvals for extra days every now and then which were always obtained by the facility and approved by insurance. After all was said and one, and she was released, we were given a bill for appoximately $20,000. The facility apparently didn't declare her "in patient" as she was and needed to be to obtain 90% coverage and they were lapse in sending in claims, leading to coverage of the much less expensive "after care" being covered while Humana's coverage for circumstances reached their limit. I have attempted to negotiate with the insurance company and also the facility (with whom I believe was negligent in their claim process)to resolve this issue, but to no avail. The facility has sent nasty letters demanding payment of $1,000/month between her dad and I and have given up on insurance. I have all the documentation regarding insurance approvals and such and also signed an agreement of $100/night (which we paid at that time) to make her eligible for the in patient coverage. Please give me some much needed advice. Thanks, Chrisy Jankowski

Attorney answers (1)

  1. Mark S Britton

    1

    Lawyer agrees

    Answered . Thanks for using Avvo. I am Mark Britton, the CEO at Avvo. I am also a lawyer. Bc we are receiving so many questions right now, it may take longer for some of our loyal Avvo lawyers to get back to you. In the meantime, I wanted to offer some preliminary help. Please keep in mind that I am not a IL lawyer, and to get a definitive answer on this you should consult a top Avvo-rated lawyer in your area.

    It sounds like the confusion comes in bc you assumed it would be "in patient." It sounds like the insurance company is simply following procedure (no matter how frustrating that procedure is). So, your only claim would be against the facility for not properly reporting her care to the insurance agency. I would contact an insurance lawyer to better understand what the facility's reporting obligation is to both insurer and insured. The fact that you were so surprised by the size of the bill is concerning.

    Here is a link to the top Avvo-rated insurance lawyers in your area:
    http://www.avvo.com/search/lawyer_search?q=insu...

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