Advocacy in Action | Claims Investigation

A member contacted her Patient Advocate to request an audit of delivery bills for her newborn baby. The PA reviewed the EOB’s and discovered that the insurance carrier had over-applied her deductible. It appeared that the member had met her deductible and out of pocket expenses of $3,125.00 on other related claims, but the carrier applied a deductible amount of $3,125.00 towards her hospital bill. The PA contacted the carrier and asked them to reprocess the bill.

After reprocessing, the carrier showed a patient responsibility of $3,018.48 due to Private Room charges. The PA investigated these charges and discovered that the hospital only offered private rooms. She provided this information to the carrier and they reprocessed the claim for a second time and removed the additional room charges. This left the member with a $0 patient responsibility.

Because the member had already paid $1,206.15 in advance to the hospital prior to her delivery, the hospital owed her a refund. The member was very ecstatic to learn not only did she not owe the hospital any money but now the hospital actually owed her a refund!

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At Brinson Benefits, we care about the patient’s best interest. We believe the patient should have an available healthcare navigator and advocate. Our Patient Advocates at The Purple Card® are highly trained to educate members about available benefit programs. They work hard to resolve issues with providers and insurers.

The Purple Card® is an independent health care advocacy and assistance service. Our Patient Advocates provide time and cost-saving services to resolve concerns about benefit programs. We not only assist our members, we educate them on ways to maximize health care coverage and other available benefit programs.