Need help or guidance..a million dollars of recalled payments
This is my story. Its a long read and I really appreciate you taking the time to read it.
Basically I am in over my head and on the brink of losing all hope. My son is severely disabled, and our insurance (which is through my employer) has recalled 3 years of payments for all his medical services. For context, one month of services is somewhere between 30-35k billed to insurance
My insurance has said they they have detected that my son has alternate insurance, which should have been primary over mine. They attest that from 2023 to 2026, they should have been secondary and recalled ALL payments. I married my spouse (my sons now step mom) in october of 2023, and we did talk about putting my son on her insurance , but I decided against it. She did end up mistakenly adding him to her insurance, for a year. I was not aware at the time but honestly I was ignorant to the fact that even if you never use an insurance, it still counts. Had I known about the insurance, I still would have thought it would have been inactive due to never being used.
Regardless now, in 2026, my insurance says that starting in 2023 (no idea how they are getting that number), my wife (sons step mom) should have been primary due to the birthday rule ( her birthday comes earlier in the year than mine). I was flabbergasted, and started trying to untangle this mess. My insurance (coincidentally me and my wife both have anthem, but hers is managed by a different company) assured me that because this was a coordination of benefits oversight, it would still be possible to file the claims with the supposed "primary" even though all this time has passed. I started that process, but also began researching the issue.
As it turns out while my summary plan description does mention the birthday rule, in the paragraph IMMEDIATELY after, it states the protocol for situations EXACTLY as mine. It lays out plainly after the birthday rule, even so far as stating "OR", that the parent who has custody pays first, then the step parent of the child with custody pays second, followed by the other non custodial parent, and lastly their spouse would be 4th in line.
I have spent HOURS on the phone with anthem trying to get this sorted out. The call before last the agent admitted it was an error (i got this call recorded ) stemming from the fact that they werent aware who my spouse was and just assumed she was his biological parent (to be clear my wife is not and she is not even his legal guardian) and that they would begin reprocessing the claims. A week later they called back with no recollection of that, instead insisting that the birthday rule stands. I have filed a formal appeal including the relevant pages of the SPD, but havent heard anything back whatsoever.
Im also not sure why they keep telling me my son had other coverage in 2023, he most certainly did not. I logged in to my wifes insurance and was able to verify he was on there for only 2024-2025. This is another brick wall I keep hitting, they just keep saying that the "system detected it". This is another issue I have no idea how to solve, I have given them my wifes information numerous times and they still havent figured it out.
To top it all off my wifes insurance has come back and denied ALL the claims because they were not submitted within 90 days from the date of service.
This has been the most frustrating experience of my life, I feel like i have proof that they are wrong but they are just NOT listening
I am truly overwhelmed and feel like everything I worked for is about to be taken from me. Any help or advice or resources would be greatly appreciated