Retro-Termination of Coverage

Retro-termination, or terminating coverage to an effective date much earlier, of a patient’s coverage is an increasing problem.  When a provider is notified of a retrotermination, the provider has already verified that the patient was covered, rendered services in reliance and expectation of payment, and, often, even received payment.  Retro-terminations magically erase coverage that was verified and confirmed and result in the provider bearing the loss, despite the fact that the provider did everything required of it.

In the group health plan market, retro-terminations are becoming an increasing problem as insurers or third party administrators (TPAs) cater to employer-clients by promising the ability to retro-terminate a policy to an effective date several months earlier.  Insurers will allow employers to retro-terminate despite the fact that they have verified coverage and eligibility after the effective date of the retro-termination.  This practice may result in payment denials or subsequent refund activity.  Retro-terminations are wrong.  Providers are severely disadvantaged when insurers verify coverage and eligibility, causing providers to treat in anticipation of payment, but then allow retro-terminations to reach back several months prior to the date of service and verification.

TGF helps clients by vigorously arguing the equities weighing against the retro-termination and highlighting contractual obligations that prevent insurers from retro-terminating to favor employers over contracted providers.  TGF identifies those state and federal laws that apply to a particular retro-termination and use whatever means necessary to rectify this abusive practice.

  • Insurers and GHPs, often acting in concert, verify benefits and coverage prior to a procedure only to later deny claims because the patient’s benefits were later terminated retroactive to a date before the service was  performed
  • Providers are generally expected to bear the loss created by the failure of communication between the insurer and GHP
  • TGF works to ensure that providers who dutifully verified benefits and complied with all necessary formalities are not forced to bear the cost of these services—when providers do everything right, they should not lose money due to the carelessness of insurers and GHPs