An Alera Group member company that provides services focused on customized, comprehensive employee benefits, HR technology solutions, and wellness services, was asked by a member to review a critical insurance claim denial, and work to overturn it. The Alera Group company served as the overall workplace benefits broker for an employer, and the employer in turn selected two affiliated health insurance companies, “Company A” and “Company B,” to provide health coverage for their employees. These employees and their dependents were thus overall members of an Alera Group workplace plan, but mainly interacted with Company A and Company B for their routine health insurance concerns.
One day, an Alera Group claims manager received a frantic phone call from a member who had just been informed that Company B denied the insurance claim for a life-saving organ transplant surgery she was scheduled to undergo in merely four days. Alera Group promised the member that they would do everything possible to help in an expedient manner.
Process
Despite being affiliated, Company A and Company B did not communicate well with each other – Company A had already approved the organ transplant surgery, but neglected to follow through and inform Company B, who then denied the transplant. Alera Group then tirelessly began calling both companies to get to the bottom of the situation.
After a lot of investigating, Alera Group determined that Company A had approved the transplant surgery, but didn’t file or process any appropriate claims for it, leading Company B to deny it. Alera Group found the correct point of contact at Company A, then quickly requested that the hospital where the member was being treated provide all claims related to the case. Because none were filed or processed by Company A and the transplant was by then just three days away, Alera Group prepared and directly submitted approximately 60 claims to ensure nothing got lost or ended up in the wrong place.
After Alera Group completed all the claims paperwork and followed up with Company A, they were informed it would take four-to-six weeks to process. Alera Group notified Company A that it was their negligence that resulted in the claim denial, and that Alera Group would inform the State of Connecticut about said negligence and the impact it was having on the member’s health. Alera Group continued to coordinate with both Company A, Company B, and the hospital until the case was complete.
Challenges
The challenges in this case resulted from the poor communication between Company A and Company B, and the complete lack of claims filing and processing completed by Company A. To compound matters, the deadline was extremely time-sensitive, and a member’s life depended on securing a good outcome in minimal time.
Results
Because of Alera Group’s diligence in investigating the case, submitting approximately 60 claim forms, and refusing to back down in the face of adversity and bureaucracy, Company A began cooperating. Within two days, Alera Group:
- Secured a check for more than $215,000 to cover the transplant expenses
- Submitted a copy of the check directly to the hospital as proof of funds for the transplant
- Ensured that the member was able to receive the life-saving transplant as scheduled
The member’s health has increased greatly, and she is still in frequent, friendly contact with the Alera Group claims manager who spearheaded this process on her behalf.
