Understanding the Order of Operations for Health Insurance Coordination

Navigating healthcare insurance can be overwhelming, especially when it involves multiple providers and insurance plans. In the case of childbirth, understanding the coordination of benefits (COB) between primary and secondary insurance providers is crucial to avoid costly surprises.

What is COB?

COB is a system that determines the order in which multiple insurance policies are used to cover medical expenses. This is important because each policy may have different deductibles, co-pays, and coverage limits. The primary insurance policy is typically responsible for paying the majority of the expenses, while the secondary insurance fills in any gaps.

Case Example: Primary and Secondary Insurance for Childbirth

Let’s consider the example of a pregnant woman who has two insurance policies: primary coverage through her employer and secondary coverage through tribal insurance. The hospital has provided an estimate for childbirth costs, indicating that only the secondary insurance is being applied, resulting in an estimated cost of $0 for the patient. However, the patient’s secondary insurance only pays after the primary insurance has been billed.

Resolving the Billing Issue

To resolve the issue, the patient must ensure that the hospital has the correct information about her primary insurance. This includes the policy number, group number, and contact information. It is also important to verify that the primary insurance is in-network with the hospital.

If the hospital continues to bill the secondary insurance only, the patient should contact the primary insurance provider and file a grievance or quality of care complaint. The insurance company’s network management team can assist in resolving the issue with the hospital.

Dispute Resolution and Legal Options

If all other avenues fail, the patient may consider contacting their local Attorney General’s office to investigate the matter. Many states have laws in place to protect patients from improper billing practices. Additionally, the patient can review the plan documents for both insurance policies to determine the specific timelines for filing claims.

Tips for Patients:

Keep accurate records of all interactions with the hospital and insurance companies.
Be persistent in following up on the status of claims.
Understand your insurance policies and know your rights as a patient.
Seek professional assistance from a licensed insurance agent or healthcare advocate if needed.