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How much to tussle with insurance companies?
Old 10-30-2009, 10:37 PM   #1
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How much to tussle with insurance companies?

I'm facing a dilemna around how deep I want to get into fighting my health insurance company.

I received about $25k worth of medical care for an accident. Originally the insurance company denied about $12k worth of that because the hospital I was brought to was not a preferred provider. I filed an appeal with the insurance company asking that all care on the date of the accident be covered at 100% as if it were a preferred provider because I didn't have any choice as to where to be taken by the ambulance and it was an emergency. They granted the appeal and did go ahead and cover most all of the $25k of care (minus my deductible of course).

However there was one bill which came in late, after the appeal was processed. There was a balance of $143 on that bill after they paid the preferred provider rate, and the hospital is billing me for that $143. I submitted a second appeal with my insurance company saying that this should have been covered under the first appeal, but the insurance company's position is that their granting the first appeal was a one time favor to me, not an admission of responsibility, and they aren't interested in doing me any more favors.

What is comes down to of course is an administrative issue; the $143 was actually included in the first, granted, appeal according to my appeal text which covered all care on that date. But their computers didn't electronically link it to the first appeal because it wasn't in their system at the time. After speaking with a few insurance company reps, it seems the only way to get this resolved is for me to request an independent review by the state insurance dept of insurance. I should also carefully review my policy to see what it says about situations where I have to use non-preferred providers; I just ordered a copy of the policy for that purpose.

I don't want to be too much of a troublemaker; I don't want to get on the blacklist of people who will never be granted insurance policies on the open market, because I may someday want to get a new private insurance policy.

So I'm considering just dropping this and paying the $143 out of pocket instead of taking it to the state board. What would you do?
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Old 10-30-2009, 11:04 PM   #2
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I would just pay it. Sounds like something that could easily take up hours on the phone and hours tracking down/sending written documentation. If it won't impact you a lot financially, i can think of many better things to do with your time, not to mention the concerns about "insurance karma."
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Old 10-30-2009, 11:05 PM   #3
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I'd just pay it, personally. In situations like this I go with the "Your Money or Your Life" theory of how much is your time worth. If you could resolve this in 3-5 hours, maybe so. But I suspect you're looking at 10+ hours (not counting what you've already spent on it). Is your time worth $14/hr? Mine is. I charge $25 just for a one hour nap.

JMHO.
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Old 10-30-2009, 11:14 PM   #4
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Yeah, just pay it......

BTW, just curious, how are your health insurance company and auto insurance company getting along? Frequently, the health insurance folks want to recoup some/all of their costs for getting you patched up from the auto insurance folks. If you were not at fault and are getting a settlement form the other driver's insurance company, your health insurance company will likely want a slice of that settlement.
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Old 10-31-2009, 07:37 AM   #5
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If the bill was higher, it might be worth the aggravation. But I agree with the others - - given that it is $143, I'd just pay it.
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Old 10-31-2009, 07:55 AM   #6
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I would contact the hospital. They forgot to include the bill in a timely manner, they could forgive it.
Otherwise I would pay it, too. (With small montly payments. Just to show my displeasure about it!!)
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Old 10-31-2009, 09:11 AM   #7
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Originally Posted by heikejohn View Post
I would contact the hospital. They forgot to include the bill in a timely manner, they could forgive it.
Otherwise I would pay it, too. (With small montly payments. Just to show my displeasure about it!!)
Close to this one.... but I would NOT pay it...

If there are billing errors not caused by you... and for some reason insurance company will not pay any provider of services... I say let THEM fight it out...


I get tired of 'it was their fault', 'you did not dot the i or cross the t so we will not pay' or 'we did what we need to do and you are responsible if they do not pay' mentality... this is one reason the system is broken....

And this is the kind of thing that needs to be in a health care bill... IF you have an emergency... and I mean a true one, not just showing up at the emergency room because you did not make an appointment.... then everything should be covered after any co-pay or deductible... PERIOD...
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Old 10-31-2009, 10:03 AM   #8
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How "late" was "late"? I had a bill come in a full year after the date of service, Thought it was odd, was sure I paid everything, so I called. They first said yes, you owe us that money, then they said they would look into it and call back in a day or two. They called back and waived it, but they did claim t was a proper charge, just late in getting out.

Had mixed feelings about it. Sure, I was off the hook, but every time they do that I'm (we all are) paying for it as part of the overall admin costs.

-ERD50
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Old 10-31-2009, 01:52 PM   #9
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Originally Posted by ERD50 View Post
How "late" was "late"? I had a bill come in a full year after the date of service, Thought it was odd, was sure I paid everything, so I called. They first said yes, you owe us that money, then they said they would look into it and call back in a day or two. They called back and waived it, but they did claim t was a proper charge, just late in getting out.

Had mixed feelings about it. Sure, I was off the hook, but every time they do that I'm (we all are) paying for it as part of the overall admin costs.

-ERD50

I don't disagree with you last statement, but if it was a company that was concerned with making money, there is not way they would have a billing system that would allow a bill to be that late...

But the 'system' is set up that way... which is why the system need to be fixed.... just throwing more people on the paying side does not fix the system (sorry, saw an opportunity to rant and did....)....
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Old 10-31-2009, 04:22 PM   #10
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I'm thinking I'll just go ahead and ask the hospital to waive it, and if that doesn't work drop it. I reviewed my policy and indeed I am responsible for charges above "customary and reasonable" for non-participating providers, so I suppose I should be thankful I got as much paid as I did.

A good reminder to make a wallet sized list of participating hospitals in your area; you can bet I've got them memorized now. I would have been out about $10k if my insurance company had held me to what the policy said.
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Old 10-31-2009, 04:37 PM   #11
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Originally Posted by free4now View Post
I'm thinking I'll just go ahead and ask the hospital to waive it, and if that doesn't work drop it. I reviewed my policy and indeed I am responsible for charges above "customary and reasonable" for non-participating providers, so I suppose I should be thankful I got as much paid as I did.

A good reminder to make a wallet sized list of participating hospitals in your area; you can bet I've got them memorized now. I would have been out about $10k if my insurance company had held me to what the policy said.
So what you are telling us is that your insurance would not cover the $10K ordinarily since it is not a participating hospital That one has me stumped... from what you said, it was an EMERGENCY... you go to where you can get service if that is true...

My mother had a stroke recently... just before her birthday... the hospital she wanted (or suggested to her) was on drive by... so they went to the next one down the road... she had no choice... we will wait and see if they try and make her pay any of the bill..

Funny thing is we tried to call and let them know since they had refused to pay $7K on another problem a year or two ago (way over priced retail, not the insurance price).... but said she did not go to a primary provider (which she did)... then they said she did not get approval to go (which she did not)... so we wanted to make sure that what we did, she was covered... and this is medicare!!! One of the HMOs that is supposed to be the 'in' thing...
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Old 02-05-2010, 07:41 PM   #12
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Will this never stop? Once I paid my $3500 deductible to the hospital, the hospital notices they've got a live one and digs around and comes up with a few thousand more in things to bill me for, all from that fateful day in April when I had the accident. So now the hospital thinks I owe them about $300 for a bill they forgot to submit to my insurance, about $900 for another bill because my insurance company is only covering at 50%, and the hospital just sent the $143 from the failed insurance appeal to collections.

This is the first time since college that I've dealt with a collections agency, and it's a bit intimidating. They say they will ding my credit report if I don't pay up in 30 days.

One positive in all this is that without my even asking, my hospital sent a lawyerspeak letter to the insurance company getting them to adjust the "Usual Customary Reasonable" up to the billed amount for the biggest bill. That actually did motivate anthem to pay $300 to the hospital.

I was investigating this today and discovered that actually California seems to have laws against the hospital billing me for charges above UCR for emergency services; they call this balance billing:

Emergency Services Billing Fact Sheet for Consumers

So in fact the $143 which is now in collections shouldn't legally have been billed to me at all! Oy, that does not make me want to pay the collections agency, but at this point the collections agency has no interest in evaluating whether the billing was illegal so they're not going to be swayed by a little thing like the charges being illegal.

I think my next step is to call the insurance commisioner's office which I should have done at the beginning.
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Old 02-05-2010, 07:59 PM   #13
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FYI here's an article on the supreme court decision that made it illegal for them to balance bill me. It was decided just a few months before my ER visit, which explains why compliance isn't up to speed.

amednews: California's high court bans balance billing :: Jan. 26, 2009 ... American Medical News

http://www.martindale.com/health-car...LLP_658158.htm
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Old 02-05-2010, 08:25 PM   #14
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I'll tell you America has the finest health care system in the world, bare none.
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Old 02-19-2010, 05:25 PM   #15
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A dozen or so phone calls later and it feels like I'm no closer to resolving these bills.

The collections agency is still calling, and even though I explained and documented why I'm not responsible they are still pursuing it.

The position of the doctors group is that the balance billing would only be outlawed if I were in an HMO, but because I'm in a PPO the law doesn't apply to me. Even though there are many interpretations saying the law applies to PPOs as well on the web, including one I sent from the CA state insurance website.

I had a conversation with the collections agent left me absolutely no doubt that there was no point in trying to convince him I'm not responsible, and he's saying if I don't get this paid off in a week it goes on my credit report. So I'm in crunch mode trying to get this resolved before that.

My next move is to get the state insurance comissioner to write a letter on my behalf. But the doctors group says that even if I got such a letter they wouldn't necessarily go by it.

When a city hospital and the state insurance commision are agreeing to disagree and putting citizens in the middle of the dispute, our system is broken. Here's hoping reconciliation works for passing healthcare.
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Old 02-19-2010, 08:03 PM   #16
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free4now,

I encountered a similar situation with my hospital. The collection agency called me after numerous back and forth with bill faxing, etc with the hospital. It appeared to me that there was no persuading that would have made the collection agency act any differently. Their job was to collect the balance from me no matter what. (They said that's what they were paid by the hospital to do regardless of circumstsances). They actually suggested to me that I paid the balance to them and continue to pursue the problem with my hospital. I paid my $500+ promptly. I never pursued it any further with the hospital either. If I had time, I would have, but it had already taken too much of my time in my opinion, and I decided to just look at it as a donation. If I had time, I most probably would have pursued, but that is not to say I actually would have gotten my money back.

I feel those big hospitals should have one centralized billing coordinator to talk to (which wasn't the case with my bills), so there was a lot of back and forth and talk to this person for this but talk to that person for that that I had to deal with, and I could never get all the parties to talk to each other. It was a lot of my precious time wasted, so I feel for you.
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