How do you deal with Insurance refusing to pay because Hospital overcharged ?

[cyber888]

The other day, I got a letter from my medical insurance refusing to pay two items in a hospital bill for more than $1500, because they think it is not acceptable the hospital is charging this. My DW was in the Emergency room for 8 hours (not overnight) and we got bill $8,600. My insurance says expect the hospital to bill you $2500. And I already got a separate bill for $310 for radiological services. And we already paid $337 on the day of the Emergency

Normally, do you call you insurance first, then haggle with the hospital. I feel the expense of $9000 for a single non-overnight ER stay is extravagant. Do you get a lawyer to deal with both? Thanks

[gauss]

Was the hospital "In Network" wrt your health insurance plan?

That is to say, has the hospital signed a contract with the health insurance company agreeing to accept negotiated rates as payment in full to the insured customers of the health insurance company?

What is not clear from your post is if this was an out of network hospital with no negotiated rates and/or if the services rendered were not covered by your policy.

A third question is what form is your health insurance (HMO, PPO, something else?)

I maintain PPO insurance and receive a monthly EOB (explanation of benefits) from the insurance company detailing all the claims and what my responsibility is for each provider. I usually won't pay a bill until the EOB figure matches what the provider is billing me for.

For hospital stays, I generally need to make a spreadsheet to track and figure all this out.

-gauss

[jazz4cash]

Quote:

Originally Posted by gauss Was the hospital "In Network" wrt your health insurance plan? That is to say, has the hospital signed a contract with the health insurance company agreeing to accept negotiated rates as payment in full to the insured customers of the health insurance company? What is not clear from your post is if this was an out of network hospital with no negotiated rates and/or if the services rendered were not covered by your policy. A third question is what form is your health insurance (HMO, PPO, something else?) I maintain PPO insurance and receive a monthly EOB (explanation of benefits) from the insurance company detailing all the claims and what my responsibility is for each provider. I usually won't pay a bill until the EOB figure matches what the provider is billing me for. For hospital stays, I generally need to make a spreadsheet to track and figure all this out. -gauss

I've always wished the PPO would send a monthly statement (EOB) with a summary of all new and pending claims for all providers and status of each claim. Is that how your PPO handles it? We get a seperate EOB for each date that a provider files a claim. There are usually multiple EOBs for a single visit (e.g. Dr, Hospital, Lab, etc.). Very confusing and extremely inefficient (but not to the tune of 9k for a visit to the ER).

[Cobra9777]

For a hospital stay or other "complicated" medical billing situation, I normally wait until I have all EOBs and all invoices, and make sure everything is reconciled. Then, if there's something I don't understand or don't agree with on the EOB, I call insurance to get an explanation or to get it corrected. Often times, insurance just wants something resubmitted with a different code, so it requires some coordination with the hospital or doctor. If you still disagree with an insurance decision or denial of coverage, there is always some sort of appeal process. I would not recommend talking to a lawyer until you've gone through that process.

If one of the invoices doesn't reconcile with the EOB, I call the provider and ask them to re-invoice. For whatever reason, this happens quite frequently. Sometime we get billed from providers that we don't recognize, typically a radiologist or similar. I'll call the provider and ask for an explanation of what service they provided, when, who ordered it, why, etc. I never pay any invoice until I have an EOB in-hand and I'm satisfied that everything is correct, reasonable, and insurance has fulfilled their responsibility.

[ndnguy822000]

Sounds like you are out of network and insurances cover ANY emergency visit regardless of where you go BUT youhave to be admitted otherwise they will not pay the bill

[cyber888]

The Hospital is In the Insurance Network - not outside. Its HMO.

[ndnguy822000]

Did you get the explanation of benefits paperwork from the insurance yet ? It should show the max out of pocket obligation from the patient and I wouldn’t pay a penny over that because hospitals play games all the time and breach the max they get paid which is not authorized based on their contract. The hospital can charge ANY amount they want which they usually do but what they get paid back is what’s in the contrac with insurance.

[MRG]

Get the EOB. Most times it's a simple coding error. I routinely get them. Last one said "this wasn't an emergency". Yeah, it was a regular office visit.

The provider sent my claim to BCBS in the wrong state!

[OldShooter]

Many good thoughts, but before you can plan strategies and tactics, you need to know the rules of the game.

Get a copy of your policy and read it (groan!) carefully. Pay special attention to "Exclusion" as the bold print giveth but the fine print taketh away. Also look for the word "Emergency."

The insurance companies' implicit objective is to make appealing a claim so difficult that you will just give up and go away. Be ready for this. Send your requests in writing wherever possible and make sure to maintain that trail. Where you have a telecon, make contemporaneous notes including date, exact time, name of the person you are talking to and employee ID number or some other identifier like call center name.

If things appear to be going into the dumper, find and use the email addresses of the top executives in the company. They have people who intercept and give special attention to customer complaints that come in to those offices.

In the end, if you feel that the company is refusing to honor its obligations under the policy, contact your state insurance commissioner. They have consumer support people and they have clout that you don't have.

[Bestwifeever]

Your insurance co has contracted rates if the ER is within network and the $8k+ is the bogus price that no one pays. Wait til you see the EOB and get billed by the ER to see where you’re at. Hope your DW is okay.

[sengsational]

That's the way I do it. They will often send a bill with a subset and try to get some money out of you early. I completely ignore anything sent before I get a complete EOB. Meaning every supplier has made their claim. Then, if the supplier has any relationship with the insurance company (negotiated rates in the secret contract that we as consumers are not privy to), I call the billing office and tell them if they want to get a dime, they need to address whatever issues I have, like an out of network contractor or something. They can send it to collections, I don't care. Unless they convince me I'm not getting cheated, I don't pay the first dime.

[Rianne]

Quote:

Originally Posted by cyber888 The Hospital is In the Insurance Network - not outside. Its HMO.

This happened to my DH, not ER but surgery in an in-network hospital. We verified all the procedures, surgeon with the main office ahead of time. Were re assured everything in network with insurance company. Got an extra bill for +/- in the neighborhood of $1500. Solution takes several calls and callbacks. It was not a coding error, the surgeon had an out of network co-surgeon help without our knowledge or approval. Very frustrating couple of weeks, but in the end the surgeon paid for his buddy to help with the surgery.

This kind of thing is nothing short of a scam. IMHO They get away with it all the time because patients are fearful the insurance company or the hospital will think poorly of them. If we don't fight for what is right they'll just keep getting away with it.

[Fedup]

I think in California, they passed a law to prohibit this practice now. I agree it’s a scam.
Here is all link regarding this subject.it echos some of the suggestions first.
https://californiahealthline.org/new...urprise-bills/

[Lakewood90712]

Often the ER is almost like a separate facility from the Hospital , with many separate medical providers , not all in network. If so, you might be able to negotiate the bills down , but it will take some work.

PS for those who know, Is "Balance Billing" prohibited everywhere ? , or just in certain states ?

[ERD50]

Quote:

Originally Posted by sengsational That's the way I do it. They will often send a bill with a subset and try to get some money out of you early. I completely ignore anything sent before I get a complete EOB. Meaning every supplier has made their claim. ....

How do you know when that is? I fortunately have little experience here, but for some minor things, I seem to get some ancillary charges months later for something related to the date-of-service.

-ERD50

[Texas Proud]

Quote:

Originally Posted by Bestwifeever Your insurance co has contracted rates if the ER is within network and the $8k+ is the bogus price that no one pays. Wait til you see the EOB and get billed by the ER to see where you’re at. Hope your DW is okay.

+1 on this... went to a stand alone emergency room for heart attack like symptoms... insurance said they did a lot of unnecessary tests and did not pay... they were in network so I did not pay... they did say I was not having a heart attack....



They transferred me to a hospital emergency room for 'observation'... also in network... they moved me to a room and I stayed most of the day.... the insurance also said THEY did a lot of unnecessary test and also refused to pay them....


I never had to pay more than my emergency room deductible...

[Texas Proud]

Quote:

Originally Posted by Rianne This happened to my DH, not ER but surgery in an in-network hospital. We verified all the procedures, surgeon with the main office ahead of time. Were re assured everything in network with insurance company. Got an extra bill for +/- in the neighborhood of $1500. Solution takes several calls and callbacks. It was not a coding error, the surgeon had an out of network co-surgeon help without our knowledge or approval. Very frustrating couple of weeks, but in the end the surgeon paid for his buddy to help with the surgery. This kind of thing is nothing short of a scam. IMHO They get away with it all the time because patients are fearful the insurance company or the hospital will think poorly of them. If we don't fight for what is right they'll just keep getting away with it.

OH YEA.... this happened to me... DW had a 5 minute operation and was charged almost a hour time of TWO Drs..... I called and said I was not going to pay for two Drs when we only needed one and BTW, it was only 5 minutes!!


They cut the second Dr fee and reduced the main Dr by 75%.... still got paid well....

[EastWest Gal]

Balance billing is still legal in most states. It is probably a coding error, or a scam ( I don’t trust hospitals or doctors offices when it comes to billing.) It looks like it’s legal in N.C.

If it is in network, then the insurance company may be at fault. But I would not trust the hospital.

Contact the patient representative at the hospital where the ER is. Determine if it is the hospital and/or the physician services that is overcharging. Tell them you are disputing the charges. Put in writing what you are disputing. Request that the charges be reviewed. They can help put a delay in the billing.

Each charge has a CPT code with it. It maybe the wrong code. You can google the cpt code in question and figure it out.

In my son’s case earlier this year, his ER visit was upcoded and the wrong code was used for a simple splint, resulting in an overcharge of several thousand dollars. The patient rep helped us get the billing put on hold indefinitely until it was reviewed and resolved. My son obtained a copy of the ER report from medical records and found numerous errors-history and physical exam portions that were not done but were documented as if they were. A $3500 bill was reduced to $108 when we were done. It took several letters and phone calls. We still weren’t satisfied because of the numerous errors in the record, but decided to give up fixing that.

The insurance company was no help at all.

Get a copy of the actual record (your wife has to go to health information and request it in writing) to see if the ER did what they say they did.

[gauss]

Quote:

Originally Posted by Lakewood90712 Often the ER is almost like a separate facility from the Hospital , with many separate medical providers , not all in network. If so, you might be able to negotiate the bills down , but it will take some work. PS for those who know, Is "Balance Billing" prohibited everywhere ? , or just in certain states ?

My understanding is that "Balance Billing" by an in-network provider will put that provider out of compliance with its contract with the health insurance
provider.

I am not aware of any Federal or State statutes that address balance billing, but they could be out there.

I generally say to the provider that their invoice is not consistent with the EOB that I received from the insurance co. Generally once they realize this, they know they have a problem on their end that they need to look into.

[MBSC]

Quote:

Originally Posted by Lakewood90712 Often the ER is almost like a separate facility from the Hospital , with many separate medical providers, not all in network. PS for those who know, Is "Balance Billing" prohibited everywhere, or just in certain states?

21 states have varying degrees of out-of-network balance billing protections. In some states the OON ER physicians are allowed to balance bill but the patient is not obligated to pay (held harmless).

Reference: https://www.commonwealthfund.org/pub...ections-states