Topic: Iowa Insurance Commissioner's response to my IA bcbs complaint on NON-payments of LLM
bettyg
Unregistered
posted
TALK ABOUT A MICKEY MOUSE LETTER i got yesterday!
from Iowa Insurance co., Des Moines
Dear Mrs. Gordon:
enclosed please find a copy of a correspondence our division has received from wellmark, inc. in regards to your inquiry to our division.
wellmark explains the CONFUSION in processing of your claims in question.
wellmark states that you will be receiving an explanation of health care benefits reflecting the processing of your claims.
we thank you for bringing this matter to our attention and allowing us the opportunity to be of service. (what service says betty!)
yasmin jeshani, insurance investigator market regulations bureau
330 maple st. des moines, ia 50319-0065
1.877.955.1212 IOWA ONLY **************************
welmark's letter now; talk about a snow job! i have emphasized certain points!!
dear ms. jeshani:
this letter is in response to your 11-27-06 inquiry received by wellmark bcbs of iowa on 11-28-06. i have the following info to provide.
mrs. gordon is enrolled in the program 3 plus plan w/wellmark. this coverage is provided thru the employer group, state of iowa, and provides benefits SECONDARY TO MEDICARE.
as such, wellmark MUST receive a MEDICARE REMITTANCE NOTICE, MRN, FOR ANY CLAIM SUBMITTED FOR BENEFITS SECONDARY TO MEDICARE !
upon receipt of your inquiry, i verified that NONE of the attached claims for service between 4-20 to 9-13-06 for mrs. gordon HAVE BEEN PROCESSED OR DENIED BENEFITS by wellmark. a review of these claims reflects the following:
. dietary supplements provided in the office of dr. v on 7-3, 7-11, and 7-20-06.
. RX drugs provided thru O'Brien Pharmacy, Cape Pharmacy, Kronos Pharmacy, and the Prescription Center on 7-5, 8-16, 8-28, and 9-13-06.
. office and/or outpatient, and independent lab services provided thru dr. V; entero lab, meridian valley lab, geneva diagnostics d/b/a/ great smokes diagnostic, lab, and neuroscience, on 4-20-, 4-21, 5-5, and 7-3-06.
as noted above, because this policy provided benefits secondary to medicare, any eligible claim for COVERED benefits for mrs. gordon must be filed to wellmark with a medicard remiittance notice outlining the benefits provided or declined by medicare.
a review of the claims submitted with this complain reflect the NONE of these charges have been filed to medicare as the PROVIDERS involved are NOT ACTIVE PARTICIPANTS WITH MEDICARE and ther3rfore the charges can NOT be submitted to or paid for by medicare !
i have referred ALL of the above noted claims for INTERNAL processing at wellmark.
betty will receive an EOB/explanation for EACH CLAIM ONCE PROCESSING IS COMPLETE.
in the event of an ADVERSE DETERMINATION OF BENEFITS, betty may file a requiest for an ERISA REVIEW WITHIN 180 DAYS OF THE "DECISION DATE" on her EOB!
i appreciate the opportunity to explain the postion of wellmark bcbs of iowa. if you have any questions regarding this info, please feel free to contact our office.
sincerely,
rhea ahlberg special inquiries wellmark 636 grand ave. des moines, 50306-9232 www.wellmark.com NO PHONE NO. SHOWN; an independent licensee of bcbs assn. ***************************************
isn't it interesting; bcbs said nothing of my and my pcp's rn phone calls to des moines where they stated i would be covered for out of state llmd expenses!?
also she doesn't state i contacted the supr. over the 1-800 of questions and told her medicare would not provide me a DENIAL of claims, but i HAD AN "OPT OUT OF MEDICARE" CLAIM FORM I HAD TO SIGN FOR DR. V IN HER OFFICE PRIOR TO TREATMENT, and they didn't say anything i'd furnished a copy of this each claim per the suprs. request!
i'll pursue on tues. when they return after NY's day! they owe me explanations now; they've had 75% of my claims since late april/early may; 8 months to process my claims! give me a break!
i've probably made 30 calls since this all began if not many more! i documented each one also.
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bettyg
Unregistered
posted
i've not had a chance to read this do to all pms i've been answering/llmds/newbie links, etc. but am going to include what i was sent yesterday! i look forward to reading this one after the above letters to me! ************************
New legal essay on UNUM/Provident Scandal Posted by: Mary Schweitzer, CFS patient on CFS ADVISORY COMMITTEE Date: Thu Dec 28, 2006 8:01 pm (PST)
Yale Law School Professor John H. Langbein has written a very insightful essay, "Trust Law as Regulatory Law: The UNUM/Provident Scandal and Judicial Review of Benefit Denials under ERISA."
I have a copy that is cited as being in the Yale Law School John M. Olin Center for Studies in Law, Economics, and Public Policy, Research Paper No. 329 and Yale Law School Public Law and Legal Theory Research Paper No. 118.
I am informed that this will be published sometime next year in the Northwestern University Law Review, but I could have that detail wrong. .
EDITED; THANKS TERRY FOR CORRECT CODING! The essay is available here:
Terry, i copied/pasted according to your email, but this has been my 6th edit and after edit post is done, it still doesn't look right to me?! but i tried it as you said to. (i'm not a very good student on this type of thing!) lol
Langbein gives a new set of arguments to use when dealing with BENEFIT DENIALS. Anyone with a current case AGAINST an insurance company will find this useful; anyone who has had difficulties with their private disability will find it very insightful.
TerryK
Frequent Contributor (5K+ posts)
Member # 8552
posted
So sorry Betty.:-( It sounds like they do not cover claims unless they are covered by medicare since they are secondary to medicare. This is the same way that my policy works (my policy is a medigap policy).
I know that great smokies is a provider for medicare since medicare has paid my claims for tests done there in the past. I don't know about the other labs. You can find out directly from the labs themselves. I wouldn't go to the trouble though until you find out whether you can actually get any of your labs covered.
You may want to ask great smokies to bill medicare. I'm not positive but my understanding is that all labs (that are approved to be paid via medicare) are legally required to bill for medicare patients so I don't know why they didn't bill for you to begin with.
According to the research I've done, if your provider (the doctor) has opted out of medicare and they do not still have a number with medicare then you can't even get your lab tests paid for. If they have opted out of medicare but they still have a number then you can at least get labs that are normally covered paid for.
From what you said before, this doctor has opted out of medicare and likely no longer has a number since she did not want you to bill anything to medicare. If medicare does not pay then your secondary insurance (medigap) probably won't pay either.
That is my experience but don't take that as fact since from what you said before, you have a different secondary type of insurance through your husband's policy rather than a true medigap policy. You will need to find out if they cover anything that is not approved by medicare or if they ONLY pay that which is approved by medicare.
I have a regular doctor who has been following all of my treatment and keeping an eye on me. He looks at my tests that are ordered from my LLMD and will order any that he feels are necessary. Since he is a provider to medicare, they will pay for tests that he orders unless they feel that the tests are not necessary. This has helped me a great deal with lab costs. So, if you must see a doctor who has opted out of medicare, find a doctor who can follow you and will order any necessary tests.
Good luck. Terry
Posts: 6286 | From Oregon | Registered: Jan 2006
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TerryK
Frequent Contributor (5K+ posts)
Member # 8552
posted
I don't see a link to the article Betty. Also, it sounds like the essay is related to disability insurance and the issues in this thread are related to medical insurance. Am I misunderstanding? Terry
Posts: 6286 | From Oregon | Registered: Jan 2006
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bettyg
Unregistered
posted
i found this; but it's all lawyer talk leaving me out of this conversation! i did find the link above, but it's pdf and 50 pages! then i saw on front page referring me to below here, so went there and copied this.
it'll take me forever to read 50 pages!! i tried!
Trust Law as Regulatory Law: The Unum/Provident Scandal and Judicial Review of Benefit Denials under ERISA
JOHN H. LANGBEIN Yale University - Law School --------------------------------------------------------------------------------
Yale Law & Economics Research Paper No. 329 Yale Law School, Public Law Working Paper No. 118 Northwestern University Law Review, Vol. 101, 2007
Abstract:
When the participant in an ERISA-covered employee benefit plan seeks judicial review of the plan administrator's decision to deny a claimed benefit , should the standard of review be deferential, effectively presuming the correctness of the denial, or should the court examine the merits afresh, applying so-called de novo review?
In the prominent ERISA case of Firestone Tire & Rubber Co. v. Bruch (1989), the Supreme Court held that, on account of ERISA's protective purpose, the standard of review should be de novo.
However, in an ill-considered aside, the Court assumed (and thus effectively decided) that the employer could alter that standard by inserting terms in the plan requiring deferential review.
Even though resolving benefit claims is a fiduciary function under ERISA, and even though plan administrators are commonly officers of the employer (or its insurer) who have a financial interest in denying claims, ERISA plans now routinely require deferential review, and courts routinely obey.
A major scandal in claims administration has come to light in recent years that underscores how dangerous it has been to allow ERISA plans to skew the standard of review towards self-serving decisionmakers.
Regulatory authorities and courts have now established that Unum/Provident Corporation, the nation's largest disability insurance carrier, was engaged in a program of deliberate bad faith denial of meritorious claims in both ERISA and non-ERISA markets .
This article reviews these events. The Unum/Provident saga shows convincingly that the Supreme Court underestimated the danger of allowing ERISA plan sponsors to require judicial deference to conflicted plan decisionmakers.
This article refutes a line of Seventh Circuit ERISA cases that deprecates the dangers of conflicted plan decisionmaking on supposed law-and-economics principles.
The article contrasts a strand of Eleventh Circuit authority that has been able to reduce the harm.
A main theme of this article is that the Supreme Court's misstep in Bruch was premised on a misunderstanding about how trust law bears on ERISA.
The Court reasoned that because ERISA is rooted in trust law, and trust law allows the settlor to alter the standard of review, ERISA should allow similar latitude to benefit plan sponsors.
That syllogism is flawed. The law of trusts is prevailingly a branch of the law of gifts, which aspires to maximize the donative autonomy of the settlor who creates the trust.
In ERISA, by contrast, Congress drew upon trust law principles in support of a regulatory purpose, restricting the autonomy of plan sponsors in order to protect plan participants.
Trust law rules that conflict with ERISA's regulatory purpose ought not to be transposed to ERISA. A variety of provisions of ERISA are shown to provide textual support for this view.
Contact Information for JOHN H. LANGBEIN (Contact Author)
Email address for JOHN H. LANGBEIN Yale University - Law School P.O. Box 208215 New Haven , CT 06520-8215 United States (202) 432-7299 (Phone)
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I'm sorry this is not getting paid. I know what you mean about the AIDS patients. I found out if I had AIDS, was in jail or an illegal alien, I would have the BEST inusrance available. But no, I'm just a taxpayer with Lyme!
Insurance companies are not in the business to lose money! They've got themselves pretty well covered.
Kayda
Posts: 582 | From midwest | Registered: Nov 2006
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bettyg
Unregistered
posted
kay, you've got that one right! but we'll keep fighting for our LYME rights/payments!
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TerryK
Frequent Contributor (5K+ posts)
Member # 8552
posted
Sorry Betty, not sure why the link isn't working. I've cut and pasted it directly out of the e-mail I sent to you and it's working fine.
The Lyme Disease Network is a non-profit organization funded by individual donations. If you would like to support the Network and the LymeNet system of Web services, please send your donations to:
The
Lyme Disease Network of New Jersey 907 Pebble Creek Court,
Pennington,
NJ08534USA http://www.lymenet.org/
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