Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan they must hold you harmless for the coinsurance charges associated with cardiac catheterization services you received at an outpatient hospital facility from February 21, 2019, to February 24, 2019.
You asked the Plan to waive the coinsurance charges associated with cardiac catheterization services you received at an outpatient hospital facility from February 21, 2019, to February 24, 2019. You say that you have tried to get this issue resolved with both the Plan and the provider numerous times. You said that you do not believe you owe $3420.65, which is the amount listed on the current Explanation of Benefits. The Plan denied your request. The Plan says that because the provider has not completed its claim review, they are upholding the billing at this time. The Plan says that they do not allow providers to balance bill members.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has stated that because the provider hasn't finished its claim review, they aren't taking any action to determine if the amount being billed is correct. This is not appropriate. This provider is a contracted provider with the Plan. The Plan has an obligation to manage their own contracted providers. The Plan has failed to do so by allowing their provider to charge a coinsurance for unexplained and unidentified services submitted on an outpatient hospital bill. There was absolutely no explanation from the Plan as to how this coinsurance amount was calculated or which section of your Evidence of Coverage would be applicable to such coinsurance. You had a cardiac catheterization, which is an outpatient hospital surgical procedure. Under the terms of your contract, you are only responsible for a $325 copayment for that service. You are not disputing that copayment. There is no listed coinsurance for outpatient surgery in your Evidence of Coverage, so the Plan has failed to meet its burden of explaining how and why any coinsurance was assessed.
Furthermore, based on call logs provided from the Plan, it is unclear if the provider is even billing you for this coinsurance at this point. The Plan has been provided with conflicting answers from their own contracted provider. As mentioned above, the Plan is responsible for managing their own contracted providers. If the contracted facility is billing incorrectly or cannot explain if you are even responsible for the outstanding balance, then the Plan is responsible for that. You cannot be held responsible for the Plan's failure to ensure
that their contracted providers follow appropriate billing rules. Therefore, we find that the Plan must hold you harmless for the coinsurance that is being charged on the Explanation of Benefits.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter