Claim retroactively denied after I already paid. Still haven’t gotten a refund from hospital 6 mos later.

I’ll try to keep this as short as possible…

My infant daughter had a hospital visit over a year ago for severe dehydration due to enterovirus. She was discharged after a few days, but had to be readmitted the same day (direct admit).

The hospital billed for the readmission. Insurance originally approved it. I paid the bill.

7 months after the visit, insurance reprocessed the claim for the readmission and denied it (original visit was not affected). I was issued an EMB with a negative patient responsibility reflecting the amount I had already paid. It is my understanding that the hospital now needs to refund this amount.

It is my understanding from a previous post and from talking to a few doctors that it’s illegal for the hospital to bill for a readmission within 30 days for the same condition. Basically they should not have discharged her in the first place, so the readmission has to be written off.

Current status is that I have called insurance and the hospital. The hospital has escalated my issue to billing/coding, but they keep telling me they “don’t have an updated EMB” and they are showing it “in review” with insurance. Insurance contacted the hospital while I was on the phone with them. They told me they put a stop payment for the check they sent to the hospital, and told me that the hospital account shows that I now owe this amount. (Imagine my surprise when I called trying to get a refund and they tell me I owe even more money!)

I honestly don’t what know what to do at this point. It’s been half a year since the “adverse benefit determination” and it’s still not resolved. Can I file a CMS complaint over this?

submitted by /u/ThatAssholeMrWhite
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