HOME » Self-Funded Health Plan Pays Up Case Study

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Blue Cross denied a hospital’s case after determining that the self-funded plan involved in the case had exhausted its funding, and that no payments could be issued as a result. The case was placed with Convergent‘s Legal Department more than two years after the services had been rendered.

After confirming that Blue Cross had already denied the claim due to a lack of funding, Convergent obtained contact information for the self-funded group that had sponsored this plan back at the time of service. After researching and verifying that this was a large and viable global business in continued profitable operation, Convergent contacted the self-funded employer directly.

The employer’s Human Resources Department manager contended that they had no knowledge of this matter and did not intend to take further action. Convergent then re-verified the employer information with Blue Cross to confirm that the correct entity had been contacted, renewed its demand for resolution with the employer and escalated the matter to the office of the employer’s Chief Executive Officer. After continuing to push the employer for resolution, a contact in its Human Resources Department was ultimately designated to address the matter under the auspices of the CEO’s office.

Convergent obtained acknowledgement from the employer that they remained responsible for this aged matter. The employer agreed to issue payment in the amount of $194,371.54, the full expected amount due on the claim.