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Alex J. Esq.
Alex J. Esq., Attorney at Law
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Experience:  Experienced Licensed Attorney
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I fell and broke my leg/foot. I have primary and secondary

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I fell and broke my leg/foot. I have primary and secondary insurance, but both have denied all the claims from hospital/doctor. I have filed numerous appeals, now the primary will only pay a small portion - for $5,500 claim, they have only agreed to pay $1,200. What should I do now?
Hello. My name is XXXXX XXXXX I will be happy to answer your question.

I am very sorry to hear about your unfortunate difficult situation.

What are the reasons given to you for the denial by both insurance companies?
Customer: replied 3 years ago.

The primary is saying that charges exceed allowable for this procedure and Referral or prior authorization not obtained. They have also denied saying hospital/medical records missing. I know they have all the records, they were sent to insurance company via certified mail and signed for. There wasn't time for a referral, I was taken to hospital via ambulance and then surgery. The secondary keeps denying until primary makes a final decision.

Thank you for your follow up.

Was the hospital that treated you outside of the insurance network?

Have you exhausted all of the appeals at this point?
Customer: replied 3 years ago.

No, this hospital is actually in-network. This is what happened - I had a Medicare Advantage plan for my insurance that we thought was primary. We didn't know that my husband's HHS thru his employer added me to his insurance by mistake. So, when I got hurt, I gave the hospital my Medicare Advantage card and was treated. I fell on Feb. 7, 2013, but we didn't find out about the other insurance until Feb. 25, 2013. This mistake made my husband's HMO my primary and my Medicare Advantage came my secondary. Once I found out that I was on his insurance by mistake, I had that corrected immediately, but the dates of service still fall under the HMO.

Thank you for your follow up.

At this point, since your husband's HMO is only agreeing to pay 25% of the entire medical bill, have you contacted your Medicaid and requested for them to review this claim and to pay the rest of it?
Customer: replied 3 years ago.

I spoke to Medicare, but they are saying that it's up to the insurance companies. Should I make more of an attempt to get the secondary insurance to pay the difference?

Thank you for your follow up.

It would be a good idea for you to get the final decision on your claim by the primary and then to turn to your secondary and demand for them to cover as much of the remaining balance as possible.

If after the secondary insurance approves the claim, there is still a balance remaining, then you can negotiate a settlement with the medical provider and in many cases they would reduce any remaining balance by as much as 60-70% or they will allow you to make very low monthly payments, until any balance is paid in full and such monthly payments can be as low as $10-$20 per month.

I wish you all the best!
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