Wednesday, May 14, 2014

IBM Medicare and OneExchange HRA claims payment processing saga

HRA payment process seemed to settle down for me after a few blips in January and February.  Unfortunately, it didn't last and today I spent 45 minutes on the phone with the claims payment department trying to resolve two claim denials.
I file my claims by filling out the OneExchange form and then faxing the form and documentation to them.  I set up an email conformation of the fax. To set that up -  go to the PayFlex site and select the notification option. I use faxes so that I will have a complete picture of what I have submitted every month.  I attach my fax to the payment documentation when I receive checks to have a complete picture.  It was invaluable to have this information for today's call because I could quickly reel off dates and payments.
The confirmation email tells me what has been processed and what is denied before the check arrives.  This month they denied two claims.  One was for our proof of medigap F premium payments.  I provided a checking account statement I generated online  showing the premium payment deductions from our account.  It is exactly the same statement I have submitted for the same claim for the 3 prior months and all those claims were paid.  This time OneExchange said there was not enough proof. The second denial was for a claim for a payment to a doctor that doesn't take Medicare. There was no proof it was not paid by Medicare.
The first representative I spoke to said she would stay on the line and bring in a funding department representative for a 3 way call.  As soon as the funding representative came on the line the inital representative was gone!  The funding representative said the medigap insurance problem was that I didn't provide a copy of the bill from the medigap insurer.  I don't get a bill.  She said I needed to get one.  I said - but it was paid for the prior 3 months without a submitting a copy of a bill. She said the claims were never paid.  I countered that they were paid and gave exact dates when the claims were paid.  Then, she said she didn't know why those claims were paid but still insisted I needed a bill this time. 
For non-Medicare doctor fee claim, the denial said I needed an EOB showing the claim had been denied. As an aside - I don't get EOBs - I am in original Medicare so I get MSNs.  But I am quibbling. I told the representative the doctor doesn't accept Medicare so he is not going to even submit a claim to Medicare.  Then, the representative said what I needed was a letter from the doctor saying he does not participate in Medicare. At that point I felt like she was making up answers.
I then asked to talk to a supervisor.  The supervisor's analysis of the denials was completely different.
 The supervisor said the claim denial for  medigap premium  was because the online bank printout I provided didn't include my name.  The online generated statement only shows the last 4 digits of our checking account and does not show our names.  I told her that the prior claims were paid.  I also said the first time I submitted a premium claim I provided a copy of a check I wrote to the insurance company to pay the January premium and it did  include both our names and account number.  Nonetheless, she is now, in May, saying it may not be enough to generate a printout that has the last 4 digits of the same account that was shown on the January check for the follow-on months claims to be paid.  She said maybe they were wrong to even pay for 3 months. She said she would send the May denial back to claims processing for a review. 
The supervisor said for the non-Medicare doctor claim I needed to write on the doctor bill that he does not accept Medicare.  I did write it on the bill but it was at the bottom.  Apparently their fax machine cut off the bottom of that page.  She could see some of the writing but didn't get it all.  She said write it at the top of the bill and retransmit it. 
I don't trust that she is right about the non-Medicare doctor claim solution.  So, just in case, I went online to and got the form to submit the claim to Medicare myself and get an MSN denial.  I am truly annoyed to have to do so - the IRS rules for HRA are quite clear - you just have to show you paid the doctor for the employer to reimburse the fee. If I am trying to cheat the system I will be the one liable - not IBM.
I continue to be underwhelmed by the knowledge and helpfulness of the OneExchange call center representatives. I feel they  "make up answers" and want to just to get us off the phone.  I suggest that if your claims are denied, when you call to resolve the problem don't trust the answers you are getting and, if it is at all complicated,  ask to talk to a supervisor.

5/20/14 Update: The supervisor was right about the medigap F premium reimbursement.  I resubmitted a different printout - a screen shot of the payment from my checking account that also showed my name.  The claim was paid. However, she was wrong about the non-Medicare doctor claim.  I did what she said but it was denied again with the same reason -- they want an "EOB" denial.  I sent in the claim to Medicare so I'll get a denial MSN from Medicare in a couple of weeks and then I'll try to submit the claim again. I feel really lucky that I know what to do - OneExchange is absolutely clueless about giving Medicare administrative advice. I also get really aggravated that we have to jump through hoops to get our health benefit.
5/28/14 Update:  OneExchange almost got the medigap F premium reimbursement right.  They reimbursed one premium for May.  However, the second premium was tagged as a duplicate even though they were the ones who setup an account to handle TWO people.  I called yesterday and even the customer representative was baffled as to why the second premium was tagged as a duplicate.  He said the easiest way to fix it was to just setup recurring premium reimbursement and sent me the forms to do it.  I was perfectly happy submitting all my claims each month so I could easily track what I had filed.  At this point - I just want to get it fixed.
6/7/14 Update:  I continue to have trouble getting reimbursement for claims paid when the medical services are not covered by insurance.  This time my claim was denied for dental services.  They wanted to see an insurance statement because my dentist's bill showed he'd submitted the claim to MetLife and it was denied (of course).  And, of course, I threw out the MetLife denial statement.  Anyway, the answer du jour is doctor/dentist bills not covered by insurance can have NO reference to insurance on them.  So, now I need a new bill from the dentist without the reference to insurance. 

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