Claim denied - I don't have to pay? (medical, plan, hospital)

[head_start]

I had surgery a few weeks ago and stayed in an in-network hospital overnight. When I got home, I had a letter in the mail saying that my insurance provider (Aetna) had denied my doctor's request for an inpatient stay. The surgery itself had already been approved.

I checked my insurance claims on their website today. The hospital billed $46K, but it doesn't look like my insurance will be paying any of that as all of the "Your Plan Pays" sections are marked as $0. In the remarks section for each service billed, it states: "You do not have to pay this. Part of this claim was denied, and the provider's contracted rate was reduced. This is because part of the inpatient stay could have been safely managed at a lower level of care." My copay amount and total responsibility are both listed as $0. There's no EOB yet (usually takes a couple of weeks to post), but I don't think it'd say much more than what's currently on the site.

I'm more than a little worried I'm about to receive a huge bill. There's no way the hospital is going to eat a $46K bill, right? Is there anything I can do now? Or do I just try not to panic and wait to see if the hospital sends a bill?

Thanks!

[jaminhealth]

Sounds to me, just wait and see what bills you get. They can't get blood from a turnip and if need be set up a monthly payment schedule..$10/mo say. Someone goofed sounds like to me.

[AZgarden]

How many hours were you actually there? Was it more than 24? I was in the hospital overnight but had to leave by 4pm the following day, so as not to incur another hospital day. You might get a bill but I would certainly appeal it. If it says it's not your responsibility, then it should not be no matter what. To be certain, call your insurance customer service, so you don't worry about it.

[SCGamecock]

Although you may have stayed overnight, that does not mean you were admitted as an inpatient. There are other lower levels of care. If you were truly admitted as an inpatient and the billing office correctly submitted the claim as inpatient, then the EOB is correct and you do not owe anything even if the hospital sends a bill. Please note that there will be separate bills and EOBs for the physician and other services (anesthesiology, etc.).

The hospital may appeal the zero pay decision and win a reversal by submitting medical documentation stating your situation was unique and required inpatient status.

Or, you may have been at a lower level of care and the hospital's billing office incorrectly submitted the claim as inpatient. In this case, the hospital may submit a corrected claim and you may receive a revised EOB for the corrected claim. At this point, I would just wait and see how it plays out since there are so many variables. Never pay a bill unless you have a matching EOB stating you owe that amount.

Also, for any EOB that says you owe a certain amount, you can still negotiate that amount down. You can ask for a cash discount, prompt payment discount, and/or set up a payment plan as mentioned above.

[head_start]

Thanks for responses!

Re: how long I was there -- I don't know when the clock starts for the 24 hours. I was asked to check in at 7am. Surgery was at 10ish. I was put in the room I stayed in overnight at around 3pm. Discharge the next day was also around 3pm.

I'm way more calm than I was yesterday when I first saw the claim denial. No use worrying about a bill that I haven't received yet! And if I do receive one, I'll definitely get in touch with my insurance to see about next steps. I do feel a bit bad because I did stay overnight and now the hospital might be on the hook for the whole thing. I'd saved up the money for the deductible and remaining co-insurance and would have no problem paying that if they appeal and get it fixed.

[KittenSparkles]

Have you met any of your deductible yet this year?

What is your out of pocket limit for the year?

[head_start]

I've met all of the of the deductible ($1500) for the year. My out of pocket limit is $3000. After subtracting the approved claims, I've got a little over $1000 left before I hit the out of pocket limit.

[toofache32]

Tough to say with the information presented, but if nobody gets paid then don't expect this insurance fiasco to last much longer before you will no longer have anyone willing to see you with your insurance. You may have won the battle but lost the war.

[Qwerty]

While it's hard not to worry, try not to worry. Until all is said and done, you won't know if the claim is really denied or not. It's possible an incorrect billing code was sent over, 99% of the time with unpaid bills this is the case and it's a hospital/facility error and not and insurance company issue. You could have been on a 23 hour observation and they sent it over as being admitted, for example. If it was a true admission and the dr felt it was medically necessary, you file an appeal, the dr submits his cause for admission, ask for a BOARD CERTIFIED MD to review your appeal and go from there. I'm also guessing since your portion is listed as $0, the claim might not be totally processed yet.

[head_start]

Thanks, Qwerty!

I did receive an EOB from my insurance, and they're still stating that I don't have to pay anything. I haven't received anything from the hospital yet, so I'm just waiting on that before figuring out what (if anything) I need to do next.