Employee Benefits Expert Discusses Benefits Verification and Payment Following Employee Accident

This case involves a third party administrator for an employer health care plan. The administrator was contacted by the hospital when an employee under the health care plan presented to the hospital for care for serious injuries after a car accident. The administrator provided verification of benefits both verbally and in writing. Both statements noted that the verification provided was not a guarantee of payment, and that payment was subject to the terms of the plan. Some time after services were provided by the hospital to the employee, but before payment was made to the hospital, the administrator learned the employee was under the influence of alcohol at the time of the accident. The administrator notified the employee’s health care plan and the denied benefits were due to the hospital as a plan exclusion applied.

Question(s) For Expert Witness

Expert Witness Response E-083644

I used to do human resources work and verification of benefits for a Children’s medical clinic. We used a benefit portal, using the insurance information provided by the patients, to verify their benefits. Insurance payments are not guaranteed in general and payments will fall upon the provisions of the plan, which is something that hospitals should be used to. In this instance, it could also be that the people who were handling the billing, most often the medical assistants, did not fully understand what the process was. Thus, this could be the result of the hospital trying to cover its mistake, because this is a huge liability.

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