subrogation issue on retirement -anthem/medicare

[carr1600]

What is the name of your state?What is the name of your state? Virginia

I was carried on anthem healthkeepers through november 30, 2004 (I turned 65 on november 20th that year and got my medicare card effective 11/1/2004. On december 1st, my medicap AARP went into effect and from my perspective, medicare became my primary insurance as of that date. i didn't know medicare would be effective on the first day of my birth month, so kept healthkeepers dependent coverage (my wife's policy with hanover schools) until end of november.

On november 4th, i had surgery for lesions on tongue and at riverside hospital in gloucester made mistake (hindsight) of giving them my medicare card as well as healthkeepers. hospital got me on phone with medicare rep at admission to determine what carrier (anthem or medicare) was primary. medicare rep said til anthem coverage ended it was primary insurer.

well, anthem paid contractual network payment as i expected and i paid the 100 copay. network savings with anthem reduced the cost of operation from 3,717 to 2,231 for a savings of 1,566. i thought all was settled. wrong.

on april 8, 2005, i received a bill from the hospital for the network savings of 1,586. seems anthem's contractor, Rawlings co, LLC sent a letter demanding that the hospital refund the 2,231 it paid asserting medicare was the primary insurer (subrogation action) and negated i assume the contracted network savings in the process. hence, the hospital's passing on that cost to me. medicare is still investigating, but the whole matter seems unethical and unfair (if legal) as i paid anthem for primary coverage and had no control over medicare's effective date of coverage. Medicare will have a higher copay/deductible anyway if they pay which i believe they should not (that will count for zip i'm sure).

so my questions are:

1.Is this subrogation action on anthem's behalf legal and within the scope and spirit of the law?

2. Which insurer under law is my primary insurer? if not anthem, then is there some recourse for being given incorrect information by the medicare rep?

3. If anthem's subrogation initiative succeeds, What are the consequences legally if i refuse to pay the hospital on the premise my contract with them (implicit) was for an operation priced at anthem's network discounted price?

4. Any other advice or recourse?

 

[purple2]

I can answer your questions as a former Medicare auditor.
"I was carried on anthem healthkeepers through november 30, 2004 (I turned 65 on november 20th that year and got my medicare card effective 11/1/2004. On december 1st, my medicap AARP went into effect and from my perspective, medicare became my primary insurance as of that date. i didn't know medicare would be effective on the first day of my birth month, so kept healthkeepers dependent coverage (my wife's policy with hanover schools) until end of november.

On november 4th, i had surgery for lesions on tongue and at riverside hospital in gloucester made mistake (hindsight) of giving them my medicare card as well as healthkeepers."
That was no mistake; it is required of you not to violate federal law by concealing insurance coverage! You as the patient do not get to choose which insurance pays; federal law does.

"hospital got me on phone with medicare rep at admission to determine what carrier (anthem or medicare) was primary. medicare rep said til anthem coverage ended it was primary insurer."
Must have been a very poorly trained admission rep. Hospitals are all required to ask Medicare beneficiaries questions such as these http://www.cms.hhs.gov/manuals/10_hospital/ho300.asp#_301_2 upon admission. Your responses to those questions determine if Medicare is primary and there is no need to call the insurer to find that out.

"well, anthem paid contractual network payment as i expected and i paid the 100 copay. network savings with anthem reduced the cost of operation from 3,717 to 2,231 for a savings of 1,566. i thought all was settled. wrong.
"on april 8, 2005, i received a bill from the hospital for the network savings of 1,586. seems anthem's contractor, Rawlings co, LLC sent a letter demanding that the hospital refund the 2,231 it paid asserting medicare was the primary insurer (subrogation action) and negated i assume the contracted network savings in the process. hence, the hospital's passing on that cost to me. medicare is still investigating, but the whole matter seems unethical and unfair (if legal) as i paid anthem for primary coverage and had no control over medicare's effective date of coverage. Medicare will have a higher copay/deductible anyway if they pay which i believe they should not (that will count for zip i'm sure).

so my questions are:

1.Is this subrogation action on anthem's behalf legal and within the scope and spirit of the law?"
Yes, if Medicare was truly primary, the other insurer is legally entitled to recoup the $ inappropriately paid out, and it is a very common practice to do so.

"2. Which insurer under law is my primary insurer? if not anthem, then is there some recourse for being given incorrect information by the medicare rep?"
No, there is no recourse; you could try to file a written complaint with Medicare, worth a try maybe but probably won't result in much. As I said before, the hospital is supposed to ask you the questions found on the web site. Responses to those is what determines which insurer is legally considered primary. I do not have enough information from your post to determine primacy. Generally (again, without full information, I'm taking a guess), if you are entitled to Medicare based on age, you have other insurance through a former employer or pension plan but are no longer working, chances are Medicare is primary. The only way to be sure is the questionnaire on the web site.

"3. If anthem's subrogation initiative succeeds, What are the consequences legally if i refuse to pay the hospital on the premise my contract with them (implicit) was for an operation priced at anthem's network discounted price?

4. Any other advice or recourse?"
Refusing to pay is a very bad idea that hurts only you and your credit standing. Pay the bills and sort this all out after the fact. If you are found to be in the right through following the appeals process, you may be refunded the money. If you refuse to pay in the meantime, you may damage your credit rating and that will not "go away" if you later "win".

 

[carr1600]

subrogation/medicare/anthem - who pays first

thanks for your advice. yesterday medicare notified me it determined itself to be a secondary insurer for that month of november, giving me til august to appeal.

so now neithe medicare or anthem are admitting to be my primary insurer and the hospital will be charging me.

my question: does medicare's determination force anthem to back off the subrogation action and pay, or can they refuse and leave me holding the bag, despite the fact that one of them or both should pay.??? If so, I need to appeal medicare's decision by august.

seems to me unfair to be caught between these three parties and to be liable simply because of disagreement over who is primary insurer.

 

[purple2]

Being forced to pay the bill because both insurers say they aren't primary "should" not happen. Laws and Medicare regulations determine which insurer is primary for you, end of story. You should file appeals asap with both insurers.

Were you working anywhere at the time you were hospitalized? Were all 3 policies in effect when you were hospitalized? Is your Anthem policy a group health policy? Which group did you get the Anthem policy from (former employer?)?

If you were retired (not working anywhere) at the time you received hospital services, and all 3 policies were in force at the time, then most likely:
Primary=Medicare
Secondary=Anthem (assuming that's a policy you have from your former employer or your spouse's employer)
Third=AARP Medigap policy

 

[carr1600]

subrogation issue: anthem/medicare

virginia

thanks again. just got off phone with anthem and they show no record of subrogation or retraction of payment to hospital. hospital has returned anthem payment as requested by their contractor, rawlings co. no record yet of that either at anthem. hospital said they would investigate further.

as for my work info, i retired several years ago. my wife retired from hanover schools on an early retirement program (2001) which in exchange for 20 days of work each year pays her 20% of her highest salary and covers her health insurance (deducted from pay) under standard school benefit. i was carried on her policy as spouse through end of november. my medicap with AARP started on december 1st when my anthem coveraage ended. medicare assumed primary insurer then and has since paid other claims.

so from all i see, medicare should have been primary during november 2004, despite my being advised to contrary by medicare. the hospital in addition, did not ask the questions you referred me to look at.

guess i'll have to wait til the dust settles and records reflect situation accurately, then decide what to do. have until august to appeal.

any other sage advice?

 

[purple2]

Hi again. Because your spouse’s insurance is through her CURRENT employment, that changes matters.

So…If:
· You are entitled to Medicare based ONLY upon age (not disability or kidney disease--if either of these 2 entitle you to Medicare you would have been informed so by Social Security and/or Medicare) AND
· Your care was not covered by Black Lung benefits, research grants, or Veteran’s Affairs AND
· Your care was not accident-related AND
· Your wife’s current employer that sponsors her group health plan employs 20 or more employees

…then the group health plan is primary, and Medicare is secondary.

If these facts are correct, call both insurers and explain that your group health plan is through your wife’s CURRENT employment. That should clear things up.

The only thing I can figure is they either do not realize your wife is currently employed (still working, even though it’s part time) or they do not consider her to be currently employed for some reason. I strongly suspect the former.

Good luck.

 

[carr1600]

subrogation issue: who pays

virginia:

thanks again for shedding light on a murky corner of reality. all of the above conditions are true, so i now understand medicare's position and will pursue resolution with anthem on the current employment coverage point.

very helpful. thanks so much for your time. best, dave