Filing Insurance Claims

by Ira M. Leff, Esq.

December 1, 2009

iAgain and again, I encounter clients who naively trust their nursing homes with major insurance coverage issues.

For example, does the Medicare supplemental insurance that I carry cover my care here? In some cases, it does not. But in many cases it covers 100 days (or more) of skilled care. (Medicare covers the first 20 days of skilled care in full, but the resident owes $133.50 per day from days 21-100.) If the supplement pays for this care, that is $10,680 that the resident does not have to pay. Many times, the nursing home files a claim with the supplemental carrier, but if it is not paid in a timely fashion, the facility gives up on collecting from insurance and bills the resident privately.

I have seen cases recently where the supplemental insurance requires immediate notification upon admission to the nursing home. Failure to do so can void the claim for coverage. Should you trust the nursing home to make the necessary call when over $10,000 may be at stake? I wouldn't.

Many nursing homes also offer to submit the Medicaid application for the resident. If you trust the facility to do so, you will have to disclose your complete financial position to the nursing home bookkeeper who may use that information against you in the future. You will have to trust this person to relay your information accurately and completely to a DFCS caseworker at the State Office. What if the bookkeeper fails to ask all of the appropriate questions and you thereby withhold relevant information from DFCS? What if the bookkeeper makes a mistake in the transmission? Bear in mind that nursing homes live for Medicare patients and loathe Medicaid patients because of the relative payment rates. Does it make sense to trust the bookkeeper to represent you when she works for the nursing home that deplores Medicaid residents?

I have a case currently where a resident who trusted the nursing home to submit the Medicaid application was denied benefits twice because of excess resources. If the resident had obtained competent advice, she would have used her resources to pay her bills and would not have accrued $10,000 of debt to the nursing home.

The point is obvious. The resident is ultimately responsible for the bill so it is not wise to delegate important tasks to the nursing home.

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