Forum - Questions & Answers

Aug 28th, 2014 - Shannan 28 

HMO Claims

I am having a really hard time getting claims paid to out of Area HMO's. These are usually patients that come in with Medi-Cal and then it is discovered later that they had a private HMO insurance that is out of the area, or in the area. My issue is the HMO denies to health plan and the health plan denies to HMO. Any ideas or resources on how I can get past these road blocks. The other issue I frequently run into are claims that are paid by Medi-Cal, the money is taken back and the patient belongs to an HMO. Any input, ideas, or help would be greatly appreciated. Thanks in advance!


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Aug 28th, 2014 - AWASKEY 17 

re: HMO Claims

Several ways to manage the problem.

Have the patient complete a form stating what their insurance is and have them sign it. If they are wrong use in an appeal process.

Another way is to verify coverage every month. Note who you talked to etc. If wrong another document in the appeal process.

Both show due diligence on your part and give you a basis for your treatment and why the claim should be paid.

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Aug 28th, 2014 - dsteed   141 

re: HMO Claims

I have occasionally needed to use the patient information form (completed & signed by the patient) to show that the patient provided misleading/incorrect information.

If the encounter involves services that require authorization, you should be able to find out about other coverage at that time.

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