Advantra PPO Gold / denial of covered claims
I had a 48 hour hospital stay in May, 2008, due to a stroke (life threatening emergency). I went to the nearest emergency room, which also was still listed on their website a month after my admission as a member provider. It is also listed in the manuals they sent me in 2008 as a member provider. They denied the hospital bill because they say the hospital has not been a member provider since April 2003. They say they can change their providers at any time, but I don't think they are allowed to do it retroactively. According to my literature, physician services are also covered if admitted to the hospital with no deductible, under my plan. They have treated the doctor bills as out patient services and, even though the doctors are member providers, according to their web site, they have applied them to my annual deductible for using out-of-network doctors as an out-patient. I have been forced to write appeal letters, which allow them to delay payment for 60 days.
I have all my membership materials, and am so happy I did not follow the instructions of the person who called me after I enrolled, who instructed me to just throw those confusing books away, all I needed to get medical care was to show my card. I am also happy that I printed out a copy of their web site listing the hospital I went to as a member provider a full month after my admission.
One of their customer service representatives outright lied to me stating that they had no record of a hospital bill for me and that the hospital must have sent it to the wrong insurance company. I insisted on a 3-way call with in-patient billing, during which I learned that the Coventry was negotiating my hospital bill as an observation, rather than an admission. How can you be negotiating a bill you never received?
Someone in government needs to do something to provide better oversight of the practices of these insurance companies. I happen to be fortunate enough to have a background in the insurance industry. How many 70 and 80 somethings would simply believe the "customer service" representative who tells them they did not understand their coverage?
I have sent complaints to various regulating agencies, along with step by step documentation from their own literature that proves I am correct, but I still have to wait 60 days, and they reserve the right to deny the doctor bills, if the hospital agrees to accept reimbursement as observation, rather than admission.