© St. Petersburg Times, published October 24, 2002
I am a retired Nassau County, N.Y., police officer enrolled in the Empire Plan New York State Health Insurance Plan through United HealthCare. I also have Blue Cross Blue Shield. I am diabetic and use the Veterans Administration for my medical care. I have used it for six years and have had no problems until May 2001.
Not one bill has been paid since that date. I have contacted everyone involved and am getting nowhere. I am enclosing the latest bills, which have not been paid. United states the bills were received too late. The VA says it sent them in a timely manner. I am on a fixed income and cannot afford to pay these bills for which I am insured. Anything you can do will be greatly appreciated. James Gilmartin
Response: We believe the problem has now been resolved. The answer from Denise Riley, service specialist with United HealthCare Insurance Co. of New York in Kingston, N.Y., not only addresses your situation, but also serves as a useful "insurance 101" primer for dealing with similar insurance issues.
The claims in question were for services at James A. Haley Veterans Administration Hospital as well as the denial of an emergency room visit on Aug. 4, 2001. Riley said the hospitalization carrier for the Empire Plan is Empire Blue Cross/Blue Shield. Charges billed by a hospital for most inpatient services and outpatient care, such as laboratory testing and the use of X-ray equipment, are generally paid by Empire Blue Cross/Blue Shield. Hospitals are responsible for submitting; claims submitted by patients are not accepted. Pretty straightforward.
However, charges billed by a physician for hospital care, including charges for medical/professional care billed by a Veterans Administration hospital, are not reimbursed directly by Empire BCBS. Rather, such charges are reviewed by United HealthCare Insurance Co. of New York, which administers the medical/surgical portion of the Empire Plan.
Riley said that when a covered individual receives covered medical services from a physician who participates in the Empire Plan, he or she is responsible only for a copayment. It is up to the doctor to submit a claim to Empire's office within 90 days following the end of the calendar year in which the expenses were incurred. Here's where you ran into trouble.
Riley said your doctors are not participating providers. When an individual receives medical services from a doctor who does not participate in the Empire Plan, he or she becomes responsible for the fees charged as well as for submitting the claim to Empire within the same time frame as above.
When a claim from a nonparticipating provider is received, Riley said United HealthCare reviews it under its basic medical program. Any available reimbursement, less any deductible and coinsurance amounts as well as any amounts exceeding reasonable and customary fees, is sent directly to the plan member along with an explanation of benefits. (If a Veterans Administration hospital was involved, however, then the benefit is sent directly to it.) You can obviously end up paying far more when you use a nonparticipating provider. Unlike when you use a participating doctor and are responsible for only a copayment, when you receive care from a nonparticipating doctor you generally end up paying more.
When a claim for services by a nonparticipating physician is denied in whole or in part, Riley said you may submit an appeal as long as you do so within 60 days following the notice of denial. Late appeals are generally not accepted for review.
With regard to your specific concerns, Riley said Empire has in fact paid claims to the James A. Haley Veterans Administration Hospital since May 2001. It paid a $33.78 benefit on Feb. 18, 2002. Also, numerous claims were accepted for consideration, and the covered medical expenses were allowed. No benefits were issued, however, because the services were performed by a nonparticipant and the covered amounts were subject to your deductible requirement.
As a courtesy to you, Riley said all your claims on file were reviewed and as a result, two claims from James A. Haley have been reconsidered and paid. You have been mailed the appropriate explanations of benefit.
Two other claims remain denied because they should have been submitted to Empire Blue Cross Blue Shield for payment. Riley said United HealthCare contacted Empire BCBS on your behalf and learned that these two hospital claims had never been submitted to it. She said the claims have now been forwarded to Empire BCBS, but she suggests you contact the VA hospital to let it know these two claims had been misdirected. The claims in question were for the use of X-ray equipment on March 9, 2001 and outpatient laboratory testing on Aug. 14.
With regard to your claim for services by the emergency room doctor, Riley said this claim was received May 20, after the March 31 filing deadline had passed. Nothing was included to indicate why it had been filed late.
Riley said it appears you were not aware of this outstanding charge until you were billed directly for it in July. Since you promptly forwarded the claim once you received it, and since United HealthCare believes you were not aware that you would be billed separately by the doctor, it has waived the deadline. In the future, Riley suggested you include a note of explanation if you have to file any claims late. Your plan allows 100 percent reimbursement for emergency room services, so United is sending you a reimbursement for the $214 charge.
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