A hospital is trying to balance bill me. How should I work that around? (medical, plan)

[Aldaoudeyeh]

I got an emergency case months ago and was delivered to the hospital by an ambulance. The health insurance denied payment claiming their plan does not cover it. The hospital then sent me a bill requesting payment of my balance.

As far as I am concerned, it is usually illegal to try billing a patient if the hospital already billed the health insurance and received a payment, even if the insurance paid a very little amount of money. Medical providers already have contracts with insurance companies that they are bound to accept whatever the insurance company considers "fair," where how much is "fair" is solely determined by the insurance firm itself.

Given that the health insurance completely denies paying, and I did not sign any contracts to cover the deficits, am I legally bound to pay that bill?

[Rabrrita]

You need to clarify what you're saying.

1. Are you saying your insurance company completely denied all payment of the services or are you saying they approved some but not all?

2. Is this hospital actually contracted with your insurance company? (Note: not all hospitals are contracted with every insurance company and some hospitals have decided to not contract with any insurance company)

[Ariadne22]

If insurance companys says services were not "emergency," that may be the basis for the denial.

Normally, even if out-of-network, at least some part of emergency services are paid for - but, unless your state law provides otherwise, you are still subject to balance billing regardless of whether or not you signed a form stating you would be responsible.

Questions:

• Have you satisfied the deductible on this policy?
• What is the name of the insurance company?
• Is this employer coverage?
• If not, provide exactly what type of insurance this is. You may have niche coverage for some issues and not for others.

[Hey_Hey]

Any insurance will cover emergency care (if it is deemed truly emergent by the prudent layperson standard) regardless of network status. If they are denying you, then it is either a mistake on the insurance part or they have determined that your visit was not truly emergent. I would contact your insurance company first to see if it can be resolved.

Regardless of the reason, once your insurance denies your claim, you still owe the money to the providers and facility that gave you service.

[Listener2307]

I'm not sure what you are saying, either. But maybe this will help.

But I got sick in Bermuda. It was cash on delivery and the tests came to $5,000. Paid with Visa; billed my insurance company, who paid $4,500.

Then the hospital billed me another $500. Said it was for reading the MRI in the middle of the night.
I refused to pay. It said "pay on Demand" and I did.
They sent it to a lawyer in Florida and I told him I was not going to pay, did not owe it, quit contacting me.
End of matter.

The issue never showed up on my credit report. My score is 807.

[Ariadne22]

Originally Posted by Listener2307

But I got sick in Bermuda. It was cash on delivery and the tests came to $5,000. Paid with Visa; billed my insurance company, who paid $4,500.

Then the hospital billed me another $500. Said it was for reading the MRI in the middle of the night.
I refused to pay. It said "pay on Demand" and I did.

They sent it to a lawyer in Florida and I told him I was not going to pay, did not owe it, quit contacting me. End of matter.

The issue never showed up on my credit report. My score is 807.

Yours will not be the experience of most mainland medical experiences. Providers send these bills for collection at the drop of a hat, these days. OP would be wise not to bank on refusal to pay if he values his credit rating.

[beachdiver]

You can check what your particular policy covers, either by looking at your policy documents or sometimes on the insurance company website. But the hospital is within its rights to bill you as long as you did receive the services. I wouldn't risk my good credit score if it was me. What I would do however, is contact the hospital business office & ask for a self pay discount. See what you can negotiate.

[Aldaoudeyeh]

Originally Posted by Rabrrita

You need to clarify what you're saying.

1. Are you saying your insurance company completely denied all payment of the services or are you saying they approved some but not all?

2. Is this hospital actually contracted with your insurance company? (Note: not all hospitals are contracted with every insurance company and some hospitals have decided to not contract with any insurance company)

Yes. It denied all of the fees of the emergency case. It was an emergency and the police have seen me and have contacted the ambulance, so the insurance is not in a position to deny payment on the grounds that emergency can be proven.

Both of the ambulance and the hospital are in-network providers.

Originally Posted by Ariadne22

If insurance companys says services were not "emergency," that may be the basis for the denial.

Normally, even if out-of-network, at least some part of emergency services are paid for - but, unless your state law provides otherwise, you are still subject to balance billing regardless of whether or not you signed a form stating you would be responsible.

Questions:

• Have you satisfied the deductible on this policy?
• What is the name of the insurance company?
• Is this employer coverage?
• If not, provide exactly what type of insurance this is. You may have niche coverage for some issues and not for others.

I live in North Dakota, and as far as I am concerned, balance billing is illegal here. In fact, I visited a clinic a month ago and I have seen some forms to sign. Basically, most of the forms were a contract to accept balance billing for different procedures that health insurance does not typically cover. This implies that in North Dakota balance billing is illegal.

It is a student insurance - UnitedHealthCare. The required amount to pay is not deductible.

Originally Posted by Hey_Hey

Any insurance will cover emergency care (if it is deemed truly emergent by the prudent layperson standard) regardless of network status. If they are denying you, then it is either a mistake on the insurance part or they have determined that your visit was not truly emergent. I would contact your insurance company first to see if it can be resolved.

Regardless of the reason, once your insurance denies your claim, you still owe the money to the providers and facility that gave you service.

The case was an emergency and there are witnesses about that.

I do not see any convincing reason that patients owe the money the health insurance would not pay. And no, getting a service willingly is not an implicit contract to accept whatever they want to charge. This is flawed logic. We may ask the following question for those who consider that a creditor is eligible to get whatever they charge:

If you (anyone that supports the eligibility of a creditor to whatever they want to get paid) visited a restaurant and got a food dish, and you were surprised with a 3000$ bill, would you accept suck it up and accept your own logic by paying that amount of money? Would you pay 1000$ for cleaning the ground if you accidentally dropped your plate in that restaurant? I do not think so. This shows how hypocritic the mentality of these guys is!

I do not oppose the free market by the way. I am a strong advocate for it and believe that it is essential for prosperity. But there must be upper limits for prices. If anyone believes otherwise, then they have no right to object to paying 10000$ for hitting someone and getting his clothes dirty by dropping his coffee. He will clean them, and you pay whatever he charges!

Originally Posted by Listener2307

I'm not sure what you are saying, either. But maybe this will help.

But I got sick in Bermuda. It was cash on delivery and the tests came to $5,000. Paid with Visa; billed my insurance company, who paid $4,500.

Then the hospital billed me another $500. Said it was for reading the MRI in the middle of the night.
I refused to pay. It said "pay on Demand" and I did.
They sent it to a lawyer in Florida and I told him I was not going to pay, did not owe it, quit contacting me.
End of matter.

The issue never showed up on my credit report. My score is 807.

Yes. I have heard about many stories in which medical providers could not collect their credit if patients used in-network providers. There are even some cases in which courts tell medical providers to return the money they took from insured patients, probably because they have already signed a contract with the health insurance to accept whatever the insurance company deems fair. I just want to know what the law is now in North Dakota.

Originally Posted by beachdiver

You can check what your particular policy covers, either by looking at your policy documents or sometimes on the insurance company website. But the hospital is within its rights to bill you as long as you did receive the services. I wouldn't risk my good credit score if it was me. What I would do however, is contact the hospital business office & ask for a self pay discount. See what you can negotiate.

Yes, the policy covers what happened to me. They have even paid for the very similaremergency cases before. The policy still did not change as well.

[Rabrrita]

On the EOB it should state exactly why they are denying payment, what does it say?

Also, not sure this is a "Balance Billing" issue as they paid nothing. Balance Billing is where an in-network provider (like a hospital with out of network services as well) gets paid less than they billed and tries to get the balance from you; hence the word Balance and Billing. In your case, it sounds more like a Denial of Coverage. Two completely different animals. So we need to know why they are not paying any coverage. That should be on your EOB along with your appeal rights.

[Aldaoudeyeh]

Originally Posted by Rabrrita

On the EOB it should state exactly why they are denying payment, what does it say?

Also, not sure this is a "Balance Billing" issue as they paid nothing. Balance Billing is where an in-network provider (like a hospital with out of network services as well) gets paid less than they billed and tries to get the balance from you; hence the word Balance and Billing. In your case, it sounds more like a Denial of Coverage. Two completely different animals. So we need to know why they are not paying any coverage. That should be on your EOB along with your appeal rights.

They were not convinced that it is an emergency. I did not call the ambulance myself, though. The police called it for me, and some people saw what happened - it was a panic attack. There is even a medical report from a nurse practitioner about having a panic disorder and anxiety disorder as well as confirmation from physiatrist about severe depression and anxiety.

So provider's eligibility to charge the insurance firm seem to be hard to deny. Medical care providers simply find it easier to get money from ordinary people rather than firms that have skilled lawyers.

What you say here is what makes me somewhat anxious about this situation; there was no payment made by the health insurance, so the health care provider may argue that this is not a balance billing in the first place.