More on Shrinking Out-Of-Network Benefits – The Claims Filing Deadline Trap

In an earlier communication we addressed the value, although dwindling value, of the out-of-network benefit. Remember, if you don’t have out-of-network coverage, and seek care from a provider outside of your Plan’s network, you won’t be covered. As a result, out-of-network benefits are an important protection even though payment rates from insurers have been driven down.

Another issue to remember when using out-of-network benefits is your Plan’s claims filing deadline. Unlike in-network claims which are filed by the provider directly to the insurance company, the patient is typically responsible for filing out-of-network claims.

A claims filing deadline is just that – a hard stop – file the claim before the deadline or the Plan has the right to deny it altogether.

How long are these filing deadlines? Today, most claim filing deadlines are 120 days, six months or a year. That might sound like a long time but when a family is reeling from the news of a serious diagnosis, it is typical that the entire focus is on the medical care for the person diagnosed and not on filing claims. We all pay dearly for coverage so to be put in a position where it’s in effect but we are vulnerable to claims not being paid, doesn’t make sense. And as a reminder to our clients, please send in information on your out-of-network services as soon as possible so that we can avoid timely filing denials. It’s impossible for us (or the insurance company) to know about out-of-network services until a claim with a statement is filed.

I recently met with a gentleman whose wife is ill. No one had filed claims for her in some time. His response was typical:

I’m working hard to keep my job and keep our healthcare coverage in place. I’m taking care of my wife and the kids and the house. I just didn’t focus on the paperwork.

He had lost out on many thousands of dollars of potential reimbursement by not following timely filing rules.

Medicare also has a claims filing deadline. It is a year. Of course, patients rarely file claims to Medicare but patients can get caught in the middle of disputes if, for example, someone who was on an active group plan becomes ill and ultimately is moved to the company’s long term disability benefits. At that time, according to the rules of insurance, Medicare becomes primary. Insurance companies have become much better at identifying when they paid as primary when Medicare should have and they want the money back.

These situations create a mess because the group plan insurer takes its payments back from in-network providers and seeks reimbursement for medical services from patients directly (and sometimes quite aggressively) for out-of-network providers.

Insurance policies are contracts and you should know policy rules to maximize your benefits. It can be heartbreaking to pay for insurance and not have it protect you when you need it most.