Insurance denied hospital bill for deceased father

[upset264]

My 92 year old father was sent from the nursing home to the ER in early January with an urinary tract infection that was not responding to treatment. The hospital diagnosed him with Fournier's gangrene and a sepsis infection. The treatment recommended was extensive tissue removal in his groin and thigh. Considering his overall health condition and his wishes previously expressed to me I chose to "make him comfortable" and let him pass. He was transferred to a hospital room, given morphine, and the next morning he was put under hospice care. Two days later he passed away.

He was in an Aetna Medicare Advantage plan. Aetna approved and paid the ambulance and doctors bills but denied the Hospital bill of just over $6,000 stating that "This is not covered. Your stay did not meet the impatient criteria. Your care could be provided without an inpatient stay." They also state "We have denied all or part of this. However, you are not responsible for paying the billed amount because you received this service from an AETNA MEDICARE PLAN (HMO) provider OR based on a referral from an AETNA MEDICARE PLAN (HMO) provider."

Predictably, the hospital sees it differently and is billing us (my father) for the full amount.

I have been in contact with Aetna about this and have a direct phone
number to a contact who actually answers the phone and seems to know what he's doing. He tells me that the hospital is bound by their contract with Aetna and under the contract the claim is denied. The hospital appealed the denial and the denial was upheld. He says the hospital cannot bill the patient for this and he has called the hospital and discussed this with them. He says the hospital can be penalized by Medicare for trying to collect from the patient. However the hospital is continuing to bill me (my father) for this.

I am conflicted on how to handle this. I am sympathetic to the Hospital. They are there when you need them and they need to get paid. The hospitals around here are in bad shape financially and I don't know how its going to get better. On the other hand, they should know what they're doing and they should be able to deal with Aetna and get paid.

So to the point of all this I would appreciate any advice or suggestions on how to handle this. It is the last remaining unfinished business from my fathers death and I would like to have it go away. The latest bill from the Hospital threatens to turn it over to a collection agency. If the hospital would take an amount similar to what they would have gotten from the insurance company I'd pay it just to make it go away. But I'm reluctant to start offering payment amounts as it suggests accepting responsibility.

 

[MichaelB]

Condolences for your father's passing.

You have no need to feel conflicted, but you must allow the insurer to deal with this. The hospital not only has an agreement with them, it is also subject to Medicare billing regulations. The hospital is acting in violation of both those things when they bill your father's estate - they're the ones that should feel conflicted.

It is terrible that they are threatening you or the estate with collections. You should file a complaint with the State Attorney General, Centers for Medicare & Medicaid Services, and the State regulatory agency for health care. At a minimum I would send a registered letter to the hospital informing them that Aetna has disallowed the amount and advised you to not pay it.

 

[Senator]

Predictably, the hospital sees it differently and is billing us (my father) for the full amount.

Whenever you get a bill, put the death certificate in the envelope and mail it back, with no money. Do not let it worry you. I did the same thing when my mother had some medical bills.

The hospital is more than used to that type of ending.

 

[easysurfer]

Sorry to hear about your father.

My gut feeling is similar to MichaelB's, about them trying to bill your father's estate.

I'm curious now, on the bill is that to your father's name or to a family member?

 

[Souschef]

My wife had a problem like this after her aunt died. They called her and asked for her aunt's address. She gave then the cemetery's address!

 

[Sunset]

I would not pay it.
The hospital has a contract and obligation to not be billing you, in fact paying this only encourages their sloppy mismanagement.
An evil thought is some manager figures to send the improper bills in cases of death as the grieving family probably just pays and the manager gets a bigger performance bonus at the end of the year.

Surely this is not the first time you have had a medical procedure, insurance pays it and the hospital then bills you,
It happened to me.
Took a phone call every time the same bill kept coming back.
I was even on a 3 way call with insurance and hospital billing manger, and after the hospital billing manager agreed I didn't have to pay and they would not bill me, Yep they billed me again !!

After just over a year, of every couple of months a bill showing up, they finally realized they were not following their own contract/agreement and stopped billing me for it.

Hopefully the next person does not have the same problem.

 

[pb4uski]

I'm sorry for your loss, upset264.

I guess I am struggling to understand why the hospital is not entitled to something for the 2-3 days of services that they provided to your ailing father since the default option was for them to discharge the patient to home since insurance wouldn't cover the care he needed and then have hospice attend to him at home.

It sounds to me like you made a decision for him to stay in the hospital rather than going home and the "cost" of that decision is $6,000. Aetna's position that the hospital should receive nothing doesn't seem fair. I would think they should at least be on the hook for whatever hospice costs they would have covered if he had received those services at home and that the estate might be responsible for the difference since a decision to utilize the hospital was made. Or perhaps agree to split it 3 ways... the hospital writes of $2k, Aetna ponies up 42k and the estate pays $2k. In the whole scheme of things $6k for 2-3 days in the hospital seems very modest to me.

But I concede that it is really a dispute between the hospital and Aetna as to what is covered under the contract that you are caught up in but it does seem that the hospital is being villainized for doing the right thing.

Good luck.

 

[Moemg]

So sorry about your Dad . I would do what Senator suggested and just send a death certificate with the next bill.

 

[easysurfer]

So sorry about your Dad . I would do what Senator suggested and just send a death certificate with the next bill.

+1. I like the idea of sending a death certificate with the next bill.

A somewhat similar situation (creditor trying to get paid) happened to me when a friend passed away. She had put me down as a contact person in case her credit card payment lapsed. After her death I got a call from the cc company. I told the caller that my friend and passed away. Then the caller asked if I was the executor of the estate (which I was not). When I said no, the caller asked if I knew who is? I said no, but did tell them the county my friend passed away at in case they wanted to verify that I wasn't telling a lie. I didn't hear from them again, so I assume the cc probably wrote the outstanding bills as not collected.

If hospitals could go after family members for their parents' or other family members' unpaid bills, I don't see how anyone can afford to retire .

 

[pb4uski]

+1. I like the idea of sending a death certificate with the next bill. ....

If hospitals could go after family members for their parents' or other family members' unpaid bills, I don't see how anyone can afford to retire .

Sending the death certificate does nothing other than making the sender feel smug... if the patient dies then the estate is responsible for any legitimate hospital bill for services provided to the decedent.

If the estate doesn't have sufficient funds to pay the bill then the hospital has no recourse against family members unless those parties previously agreed to be financially responsible for those bills.

https://www.consumer.ftc.gov/articles/0081-debts-and-deceased-relatives

 

[easysurfer]

Sending the death certificate does nothing other than making the sender feel smug... if the patient dies then the estate is responsible for any legitimate hospital bill for services provided to the decedent.

If the estate doesn't have sufficient funds to pay the bill then the hospital has no recourse against family members unless those parties previously agreed to be financially responsible for those bills.

https://www.consumer.ftc.gov/articles/0081-debts-and-deceased-relatives

Thanks. That's a really informative link. Especially the part about whom the collector can talk to:

Under the FDCPA, collectors can contact and discuss the deceased person's debts with that person's spouse, parent(s) (if the deceased was a minor child), guardian, executor, or administrator. Also, the FTC permits collectors to contact any other person authorized to pay debts with assets from the deceased person's estate. Debt collectors may not discuss the debts of deceased persons with anyone else.

 

[spncity]

the estate is responsible for any legitimate hospital bill for services provided to the decedent.

Sorry for your loss.

The insurance company has notified you that, by contract, neither your dad nor his estate is responsible for the bill.

That being said, the system that spits out the bills will likely continue to do so for awhile. It costs them more to stop it than to continue to mail the bills.

Still, you can write another letter, enclose copies of the insurance determination, send it certified to the director of billing, and copy it to the hospital president. Might help.

If you want to help the hospital - an important part of the fabric of the community - a philanthropic contribution in honor of your dad (from the estate or otherwise) can inspire others to give as well.

Kindest regards.

 

[upset264]

Easysurfer,
The bill is in my fathers name, (not estate).

 

[upset264]

pb4uski,
Under Medicare hospice care is handled differently. Original Medicare pays the agency. The hospice agency pays the hospital for the room. There was no problem there. The bill is for the ER and first night only. What a complicated system.

 

[pb4uski]

Since your dad has passed all bills outstanding in his name are the responsibility of his estate so they are one and the same.

 

[easysurfer]

Easysurfer,
The bill is in my fathers name, (not estate).

Since your dad has passed all bills outstanding in his name are the responsibility of his estate so they are one and the same.

That is where I was leading too.

 

[upset264]

That is where I was leading too.

Sorry to hear about your father.

My gut feeling is similar to MichaelB's, about them trying to bill your father's estate.

I'm curious now, on the bill is that to your father's name or to a family member?

Point was its in his name not mine. I signed everything for him for the last few years but always very careful to sign as Attorney-in-fact for XXX.

 

[MichaelB]

My 92 year old father was sent from the nursing home to the ER in early January with an urinary tract infection that was not responding to treatment. The hospital diagnosed him with Fournier's gangrene and a sepsis infection. The treatment recommended was extensive tissue removal in his groin and thigh. Considering his overall health condition and his wishes previously expressed to me I chose to "make him comfortable" and let him pass. He was transferred to a hospital room, given morphine, and the next morning he was put under hospice care. Two days later he passed away.

He was in an Aetna Medicare Advantage plan. Aetna approved and paid the ambulance and doctors bills but denied the Hospital bill of just over $6,000 stating that "This is not covered. Your stay did not meet the impatient criteria. Your care could be provided without an inpatient stay." They also state "We have denied all or part of this. However, you are not responsible for paying the billed amount because you received this service from an AETNA MEDICARE PLAN (HMO) provider OR based on a referral from an AETNA MEDICARE PLAN (HMO) provider."

It looks to me as if the first night in the hospital your father was admitted "under observation", which Medicare will not reimburse. Typically, when this happens the hospital bills the patient, who is expected to pay the full amount. It is a nasty black hole between hospitals and Medicare and unknowing patients are exposed.

In the case of a Medicare Advantage plan, however, the insurance company agreement with the hospital would prevail. If it is an HMO plan and the facility is in network there is no question the charge does not apply.

Hospice should have been brought immediately when your father was hospitalized and not the next day. The hospital knows this and it is up to them to manage the hospitalization process so that it complies with insurer requirements.

 

[Senator]

Sending the death certificate does nothing other than making the sender feel smug... if the patient dies then the estate is responsible for any legitimate hospital bill for services provided to the decedent.

If the estate doesn't have sufficient funds to pay the bill then the hospital has no recourse against family members unless those parties previously agreed to be financially responsible for those bills.

https://www.consumer.ftc.gov/articles/0081-debts-and-deceased-relatives

That all may be true, but if the estate was only a few thousand, and the $6,000 was a significant part of it, it falls into the category of unsecured debt. No hospital, or any creditor, will chase $6,000 from an estate that may not even be worthwhile. If it was $100K, and much of that goes through probate, then that maybe different.

If most of the estate doesn't go through probate, I would not worry about the hospital.

And I would send a copy of the death certificate, not a certified one. Those cost money.

 

[Bamaman]

He says the hospital can be penalized by Medicare for trying to collect from the patient. However the hospital is continuing to bill me (my father) for this.

So to the point of all this I would appreciate any advice or suggestions on how to handle this. . . .The latest bill from the Hospital threatens to turn it over to a collection agency. . . .I'm reluctant to start offering payment amounts as it suggests accepting responsibility.

I want every hospital to get their just reward. But it's their responsibility to properly administer their billings in line with Medicare standards and regulations. If they're incapable of handling their billings, too bad.

The billings will continue until someone at the hospital takes it on themselves to do a journal entry in their books to write the debt off. Have you attempted to face a real person in the billing department face to face?

What do you care if they turn it over to a collection agency? They probably won't even know who to call or contact to attempt to collect. Next thing, they'll probably tell you it's going to affect your father's FICO score.

Vanderbilt Hospital and their regional partners refuse to accept patients on Mediicare Advantage plans That includes 1700 physicians and nurse practitioners offices in 5 states. This is a strong indication that the Medicare Advantage administration is in complete disarray.

 

[Walt34]

I wouldn't pay the bill either from the estate's funds or my own. The hospital is not following the Medicare and insurance co. rules that they agreed to. I suggest you simply ignore the bills from here on, or if you want to, call the hospital once in a while and try to get someone who knows what they're doing.

It's going to collections? So what! It is not a legitimate debt and the executor of the estate has no obligation to pay it. After a while they'll give up.

 

[aja8888]

pb4uski,
Under Medicare hospice care is handled differently. Original Medicare pays the agency. The hospice agency pays the hospital for the room. There was no problem there. The bill is for the ER and first night only. What a complicated system.

I'm just making an observation here: Sounds like your dad was enrolled in a Medicare Advantage plan rather than having traditional Medicare with an optional supplemental insurance plan (sometimes referred to as a Medigap policy).

The Medicare Advantage insurer should be responsible for the approval of services as they are the ones paying the providers, not Medicare or your dad.

 

[MBSC]

It looks to me as if the first night in the hospital your father was admitted "under observation", which Medicare will not reimburse...

In the case of a Medicare Advantage plan, however, the insurance company agreement with the hospital would prevail.

My condolences to the OP.

To clarify, original Medicare covers observation stays when the medical notes support it. Original Medicare does not cover a subsequent SNF stay after observation.

Medicare Under Observation

 

[GrayHare]

The executor might tell the hospital the estate does not have enough money to pay all bills of this type. In such situations, other creditors, such as the state, have priority and the hospital might wind up with $0. They know this so will negotiate the bill way down. The executor can offer 10% up front and the hospital may accept. Get it in writing as such a document may be reviewed during probate.

 

[pb4uski]

That all may be true, but if the estate was only a few thousand, and the $6,000 was a significant part of it, it falls into the category of unsecured debt. No hospital, or any creditor, will chase $6,000 from an estate that may not even be worthwhile. If it was $100K, and much of that goes through probate, then that maybe different. ....

The hospital has no way of knowing whether the estate is $6,000 or $60 or $6 million... all they know is that the estate owes them $6,000 (or so they think but it sounds like they are probably wrong on that). If you send them the death certificate it gives them no more information than they had before.