Another Medical Bill/Insurance Thread (plan, hospital, doctor, benefits)

[CD's Only Mrs. X]

Ok....

A few months go Mr. X went to the hospital. Two weeks later the ER doctor medical bill company sent us the bill of $255.00. That same week the insurance company sent us an EOB that stated we were only responsible for $91.71 to be applied to our deductible and that the remainder $163.29 was a discount applied due to an in network facility used in which we are not responsible for. The medical billing company told us that we were responsible for that amount $163.29.

I spoke with the insurance company who stated only to send the amount of $91.71 to the medical billing company with the EOB. I sent the amount $91.71 and all copies of letters. Two months later we get a letter threatening collection of $163.29. I spoke with the insurance company again and sent all copies of the EOB, check and correspondence with the medical billing company who are denying that they have anything to do with said insurance company. Twice the insurance company said no we don't have to pay it.

SO lo and behold today I contact the insurance company and they told me that we are now responsible for this bill and a new explanation of benefits is being sent to us.

To be honest I don't know who to believe and I am really frustrated. Every person I spoke to is documentated and it is not about paying the bill, it is about being charged appropriately.

Mr. X feels that I should contact the insurance company and write a letter with appeal because now nearly three months later, they decide the doctor is no longer in network after the EOB says otherwise?

Anybody had a similar situation like this?

[Jillaceae]

I did medical billing follow-up for quite a while, and I can tell you that it is common for insurance companies to take a contractual discount that may not actually exist. Just because your EOB states they are taking a certain discount does not mean that the company is actually contracted with your provider, or that your provider participates in the discount.

Pretty much it is a tactic used by some insurance companies to get you mad at your provider instead of them when your bill is higher than you expect it.

However, if your provider should be taking the discount, then you should be mad at them. I would suggest you call your provider and ask them simply why they are not honoring the discount. (Don't ask the insurance company- many companies do not train their CS staff to be able to answer questions like these, and the nature of contracting is that your provider has a better idea of who they contract with than your insurance company does because your insurance company is dealing with a larger volume of contracts.) Don't fool around- if the person you are talking can't answer your question, ask for a supervisor. This is not a complicated question, and should be easily answered. If they don't honor the discount, then yes, the bill is yours. If they do, you should receive no more bills, plus an apology.

Edit: One more thing: contracts are renegotiated to beginning of the year. It is odd at this time of year to have a contracting snafu. But some companies are really not good at keeping track of things like this. (For instance, Cigna.) While it is really bad customer service, I also don't think an appeal would likely change the outcome. (But if you still want to try go for it.)

[bluedevilz]

Where in the world are you that an ED visit only cost $255?

[Jillaceae]

It sounds like it is just the physician bill, not the bill for the visit. That would be about normal.

[CD's Only Mrs. X]

Originally Posted by Jillaceae

It sounds like it is just the physician bill, not the bill for the visit. That would be about normal.

Thank you so much Jill! I truly appreciate it. You have given me a more clear answer than the billing company or the insurance company could give. Yes its the physicians bill not the ER bill. That bill funny enough was less!

[Jillaceae]

MrsX, did your hospital accept a discount on the hospital charges?

[CD's Only Mrs. X]

Originally Posted by Jillaceae

MrsX, did your hospital accept a discount on the hospital charges?

Yes it did. The bill was original around $700 and we only paid $100.

[Jillaceae]

Well, an issue with an ER doc not being contracted when a hospital is certainly does happen, and while they have every legal right to bill you the way they are if this is the case, it is a big customer service issue because you don't get to choose which doctor you see in the ER.

If you wanted to, you could call the hospital and nicely point out the problem: how can you trust their ER if you don't even know that you're insurance will pay for your doctors? Especially if your plan is some sort of managed care plan, like an HMO or a PPO that they are participating in, that is a pretty big boo-boo in their part. Depending on the person you talk to, or the relationship between who does the hospital billing and who does the doctor billing, it is possible that you might be able to talk them into giving you a discount. Be "very concerned" but very polite. You could mention this creates a certain amount of distrust between you and the facility. Perhaps they can do something to rectify that.

It might not work, and again, they aren't legally obligated to if the doctor really doesn't participate in the discount or network, but I can tell you that because it is kind of a crappy situation, it is definitely within the realm of possibility that you could talk your way into the discount regardless. I've seen this situation come out both ways, depending on where I worked.

Only, make sure you are sure the discount on hospital portion is correct. I have seen many a person try to argue charges when one bill is paid differently than another, only to find out the bill they owe more on is the one that was paid correctly, and suddenly they now the owe more money on the first one. That's no fun.

[justNancy]

Originally Posted by bluedevilz

Where in the world are you that an ED visit only cost $255?

Funny, that was my first reaction.

I was in the ER in May (and admitted to the hospital) My hospital bill was about $15,000 and I got a big discount, but billing by the doctors was handled separately. The ER physician's billing service charged $758 and letting me send in a monthly payment.

[CD's Only Mrs. X]

Originally Posted by justNancy

Funny, that was my first reaction.

I was in the ER in May (and admitted to the hospital) My hospital bill was about $15,000 and I got a big discount, but billing by the doctors was handled separately. The ER physician's billing service charged $758 and letting me send in a monthly payment.

No he wasn't admitted Nancy. Thank God for that because I really would have been screwing.

For us the problem isn't paying, its more that the everything is being billed or discounted appropiately. I have heard of medical billing companies actually billing the patient first without applying health insurance (and I just received another bill from the same company for another incident for this doctor and a completely different charge amount. I called the company again and they NEVER billed my insurance company. I confirmed it with the insurance company to see if they received a bill and they said no), then once receive payment they bill the health insurance company to collect again. I refuse to pay twice for something so I want to go through all the appropaite channels.