A client recently told me of the challenges they went through dealing with nursing home bills of a family member received from an outsourced and out of state entity. The nursing home is a nonprofit organization.
The family member has Cadillac coverage. The Medicare supplement plan is a Plan G, the richest benefits offered in the supplement market. They also have a Long-Term Care (LTC) policy that covers nearly all the daily rate charges in the nursing home, all but around $3.00 a day.
The nursing home billing practices are less than desirable, advance billing for the following month. No LTC insurance company is going to pay for services that have not been performed yet, and at $23,000 a month (multiple of daily rate) we’re talking serious money. Why the nursing home advance bills makes no sense, they know the insurer won’t pay. What if the patient is transferred, discharged, or dies mid-month, why would anyone pay up front for a full month?
The nursing home’s outsourced billing agency sends out monthly statements after claims are submitted to the insurers but before the claims have been paid. The statements do not reflect negotiated rates actually paid to the nursing home by the Medicare, Medicare supplement, and LTC insurers.
The statements do not make clear which insurer is being billed and how much. LTC is very complicated. For a new patient some days of the month are covered by Medicare and the supplement, the other days by the LTC carrier. In this particular case the family member handling the patients bills discovered that the nursing home was paid twice for nearly two weeks of care. At no time did the nursing home return unearned monies or issue a credit.
After several emails, phone calls, and lots of documentation the outsourced billing provider issued a refund. But the refund isn’t the end of the story. The family member had to notify the LTC insurer of the overpayment and adjust their records, otherwise the patient’s lifetime maximum would be less the refunded amount.
Vigilance is the name of the game… and keep records! Had the family member not gone the extra mile and kept meticulous records, their loved one would be out nearly $12,000!