The Claimant was an advanced-stage lung cancer patient. He had COBRA available through his previous employer, but had let the coverage lapse, under tremendous emotional and financial strain. Having been out of work for some time, he decided he did not have sufficient funds to pay the premium, ignoring the potential long-term financial consequences for his family. To win this case, HCFS had to work around a belligerent and uncooperative human resource department with the patient’s previous employer. The challenge was to get the Claimant’s personal COBRA information sent directly to the HCFS representative. The employer sent the patient the COBRA information weeks earlier, but the patient threw it away. After much persuasion, the HR representative reluctantly sent the information to HCFS. It was a very tight schedule so HCFS had to work quickly to obtain the Claimant’s signature on his insurance paper work, as well as get payment submitted to the previous employer to cover the COBRA premium for the month of services. After the premium was paid to the employer, the medical expenses were submitted. However, the insurance carrier would not pay because the premium payment was never forwarded to the insurance carrier from the employer’s HR department. HCFS again had to contact the HR department and request payment be immediately submitted for the premium so that medical expenses could be paid. The employer was quite angry, and not accustomed to being followed up on so closely. Sadly, the Claimant passed away about two weeks later. The COBRA carrier ultimately received their premium and the medical bills were re-submitted and paid. The Claimant’s wife lost her husband, but she was not left with innumerable medical bills to worry about for years to come.
The patient was a baby born prematurely in an out-of-state hospital. The original claim was denied for patient not eligible and no inpatient authorization. To obtain payment for this service, HCFS had to prove the patient was eligible and obtain retro-authorization for the dates of service. The claim also had to be filed according to the home state specific Medicaid guidelines. In this particular out-of-state hospital, the baby is covered under the mother’s Medicaid number until the mother’s discharge. If the baby is not discharged at the same time, as in this case, the baby needs his or her own Medicaid number. HCFS contacted the appropriate agencies to obtain a Medicaid number for the baby. When requesting retro-authorization for the dates of service, the Medicaid agency incorrectly listed the authorization under the mother’s Medicaid number, causing the claim to again be denied for no inpatient authorization. HCFS appealed the denial while completing the necessary forms and gathering the required documents to obtain authorization under the baby’s Medicaid number. Due to this lengthy process, the claim was again denied even when filed with the correct authorization number. This time the claim was denied for timely filing and total claim billed exceeding the dollar limit of $99,000. HCFS then had to prove the claim was filed within the original timely filing guidelines. Each time the claim was filed, it was denied for an invalid reason. HCFS subsequently appealed the denials and worked with the Medicaid agency following up every 14-30 days until claim was approved for payment.