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Old 09-01-2017, 10:30 PM
 
1,793 posts, read 660,047 times
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I've searched all over the web for an answer on this and I can't seem to find one. I hope someone here has some experience with this.

I was in a minor accident, while out of town, a couple months ago my boyfriend took me to the emergency room. This particular emergency room wasn't in my network but it was the closest (The nearest in network emergency room was a good 3 Hour drive away and this was a real emergency. I had multiple broken bones from the fall and was in shock and actually passed out twice. I ended up needing surgery to fix The worst break. But luckily I went home for that and it was all covered because I did everything in network).

Anyway, to shorten the story, I've just now started getting some medical bills. Most of them seem legit to me. But there are two that my insurance isn't paying. I don't expect them to pay 100% of those bills, but I think they should at least pay the out of network percentage that spelled out in my plan. Together the bills are $1400.

In case you're curious, I called and the reason they didn't pay these two bills is because they said I used an out of network doctor and I used an out of network radiology unit. But it isn't like I had a choice in the situation. They did pay for the actual hospital bill which was a few thousand dollars even though the hospital itself wasn't in network. So it seems inconsistent.

I want to appeal those two bills and I figured out that process. My concern is during my research on how to appeal, I discovered that medical bills tend to go to collections quickly. How can I avoid having my bills go to collections and avoid paying them while I wait for my appeal to my insurance to go through? I have never paid a bill late, ever. I don't want any kind of stain on my credit report.

I did find out that if you dispute a bill with the doctor's office they can't send it to collections and have to give you two more months. But I'm not disputing the bills as they seem to be correct. I double checked every line item and medical code. I'm just disputing the fact that my insurance didn't pay for things when I think they should have.

I have an emergency fund and can easily pay the money right away if that's really the best option. But I don't want to pay the money if it's something that my insurance should be paying.
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Old 09-01-2017, 11:00 PM
Status: "Truly Thankful. Happy Thanksgiving to all." (set 9 days ago)
 
Location: Spurs Country
2,496 posts, read 3,058,328 times
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Call the office/billing department of the company who is billing you and talk to the staff member. Have him/her put a note in your file (on computer now, of course) explaining you are working with the insurance company to get this bill paid and you don't want it to go to collections. I have done this numerous times in the past while waiting for labs or my doctor's office to re-code the procedures correctly so my insurance would pay.

Then, as it drags out, just keep in touch on a regular basis. "Hi, this is BellaLind, just want you to update my account with a note that I am still working with the insurance company, this will be paid either by them or by me at some point".

I have had to go months this way before some of these instances were finally resolved, and always in my favor! "The squeaky wheel..........."

Always, tho, take notes with the date, the time, who you spoke with, and the conversation in brief. CYA. Keep all paperwork together, including any billings, or notices. If you get any of these, that is a good time to call and update the status of your appeal.

I have also done 2 appeals for denied claims, both of which I won. Take time to really go into detail, and use "key-words" that will have a strong meaning in describing your reason for appealing. It can be a PITA but well worth it when you win and don't have to shell out your hard-earned money when the insurance should be paying for it.

And don't worry, it will get resolved, most likely without any "hits" to your credit!
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Old 09-02-2017, 10:20 AM
 
Location: Somewhere in northern Alabama
15,569 posts, read 47,078,378 times
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The general outline Lodestar gave is fine, but I go into these situations by REFUSING to use the phone under any circumstances. ALL communication has to be in person with witness, or preferably in writing. I typically will copy my letter to the insurance company and the provider, with both going certified mail. I then staple the cert. mail receipts or return tag to my copy of the letter for filing.

I had to laugh the other day, because a disputed bill from a provider that had been under my insurance plan - from two years ago - was finally paid by my insurance company and out of the original bill of over $200, my share was $10. For the two years, that dispute was hanging, but couldn't be sent to collections as an ignored unpaid bill, because I had written proof of my dispute.

After a horrible experience a few years back, I now look at any medical billing as an adversarial contest, where the provider wants money and doesn't care how it comes, and the insurance doesn't want to pay and doesn't care if that involves "errors" that erroneously deny claims. In other words, if you don't protect yourself, you WILL get stuck.

By having everything in writing with return receipts I accomplish two things - no harassing calls or continuing attempts to brow-beat by duplicate bills, and if I did have to take it to court, the judge would look at my documentation, smile at me and tell the fools to bill properly, code properly, pay properly, and leave me alone.
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Old 09-02-2017, 11:19 AM
 
Location: Florida -
7,447 posts, read 8,660,696 times
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You can certainly dispute or appeal this legitimate claim with your insurance company -- and perhaps they will even pay it, but it's unlikely. On the other hand, even as much as they tend to overcharge, you sought the services of medical professionals - and cannot expect them to work without compensation.

It's unfortunate that this emergency situation caused you to go out-of-network for treatment. But, even when you checked-into the hospital emergency room, you provided your insurance information and agreed to pay for any services not covered by your insurance. Remember, this is YOUR debt, not theirs! They are out-of-network for a reason and it is not their fault that your insurance did not cover your claim.

Perhaps you can ask the billing department to avoid sending your claim to collections, but, it is unlikely they will do so, unless you at least arrange and start some type of payment schedule. IF your appeal is granted, the medical provider will refund your over-payment, but, if it is rejected, you will already be on your way to paying off "your" debt. - Simply ignoring the bill and hoping that collection efforts do not damage your credit - is a poor choice which will cost you in the long run.
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Old 09-02-2017, 11:49 AM
 
760 posts, read 503,211 times
Reputation: 1261
I had to go to the ER a few years ago for a very painful white head on my pinky. It was throbbing and by 10 pm Sunday night, I couldn't sleep, so I drove myself to the ER without even telling my wife. By 2pm, I asked when I would get out because I had to work at 6:30 that morning. I was told I wasn't going anywhere because there were red lines going up my arm and was told that when they reach my heart, I would be dead. They said if I didn't show up when I did, I would not have woken up the next day. I had a MRSA a staph infection and was in the hospital for a week.

The plastic surgeon who was called in was out of network. He sent me a bill for an additional $1000 over and above my $70 co pay. I called and told them they must have made a mistake. He said something about a deductible and I told them I do not have a deductible. They then said he was out of network, so my health insurance pays (with $1000 dead) in lieu of my hospital coverage. I then called the hospital and screamed at them for calling an out of network doctor when they knew full well which insurance I had. After talking to the surgeon, he said if he was unable to get the additional charge from my insurance company, then they would. Accept the in network payment and I would be off the hook.

Two years later, the same thing happened. I had a painful white head on my index finger. I went to a walk in clinic. They told me I had MRSA and to go to the ER. I did and I sat around for two hours and waited. Someone came in and drained it. Once again, I got a bill. Same as above, different doctor. I told hi I wasn't paying. He already got $4000 for the 10 minutes he saw me and it was not my fault the hospital matched me up with him. He didnt care and insisted on the $1000 difference. I have been sending him letters for 3 years now telling him I am never paying and it isn't my fault he feels his services are worth the extra $1000 that all of the other doctors in his field will accept. I also told him thTh he should have disclosed that he was out of network. At least I could have had the opportunity to refuse the service and ask for someone in network.

A year later, my 5 year old daughter fell backward in her chair in Kindergarten. My wife took her to the ER and she had to get stitches. Lucky me, she was seen by the second doctor above. Same situation. Out of network. I called and said I wasn't paying. I called my congressman and was told that as of 2015, NY now has a surprise bill law that protects anyone who is seen by an out of network doctor in the ER. They are forced to accept the in network fee. I filed the papers and the doctor still tried to to collect. In the end, he had to take it and I am off the hook for that bill but still fighting the second one. I will probably take the hospital to small claims court for having an out of network doctor that me when they were aware of my plan. Why do they bother asking if they ignore what you say and make a decision that costs the patient a large amount of money without any notification of that.

See if your state has this law. Good luck.
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Old 09-02-2017, 03:30 PM
 
Location: Florida
3,065 posts, read 2,353,700 times
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I think you got good advice above. Don't worry and do not get upset. You should find the hospital understanding as this has probably happened many times.
Yes put everything in writing. I would use email as it is quicker. If you have a phone call then I would email back a summary of the conversation.
I was in an automobile accident and my wife was taken to the emergency room.... The insurance company paid a few thousand for the emergency room services but refused to pay the ambulance. Not necessary. Took over a year to get paid. The ambulance company was more than understanding and very cooperative. I also had problems with the hospital and finally had to write the Chief Financial Officer. He assigned a clerk to investigate and everything worked out. Point is you do have to find someone who is interested in solving the problem.
Might look to see what help the hospital may give you. I had a local hospital who had a person assigned to resolving all insurance problems. You give them the bill and it probably will get paid.
If it goes to collections write the collection agency and explain. If they report to the credit reporting co's you can add a statement to the credit report.
I would consider your state's insurance department. Seems there should be a network exception some place in the rules.
Good luck
PS I agree not to pay.
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Old 09-02-2017, 03:34 PM
 
Location: Orlando
1,421 posts, read 1,980,430 times
Reputation: 4517
Quote:
Originally Posted by rjm1cc View Post
I think you got good advice above. Don't worry and do not get upset. You should find the hospital understanding as this has probably happened many times.
Yes put everything in writing. I would use email as it is quicker. If you have a phone call then I would email back a summary of the conversation.
I was in an automobile accident and my wife was taken to the emergency room.... The insurance company paid a few thousand for the emergency room services but refused to pay the ambulance. Not necessary. Took over a year to get paid. The ambulance company was more than understanding and very cooperative. I also had problems with the hospital and finally had to write the Chief Financial Officer. He assigned a clerk to investigate and everything worked out. Point is you do have to find someone who is interested in solving the problem.
Might look to see what help the hospital may give you. I had a local hospital who had a person assigned to resolving all insurance problems. You give them the bill and it probably will get paid.
If it goes to collections write the collection agency and explain. If they report to the credit reporting co's you can add a statement to the credit report.
I would consider your state's insurance department. Seems there should be a network exception some place in the rules.
Good luck
PS I agree not to pay.
Email is quicker, but you don't have proof that it was received. That's why Harry Chickpea recommends certified mail, return receipt requested, and I agree with his recommendation.
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Old 09-03-2017, 06:00 AM
 
Location: Central Massachusetts
4,101 posts, read 3,695,137 times
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Quote:
Originally Posted by WellShoneMoon View Post
Email is quicker, but you don't have proof that it was received. That's why Harry Chickpea recommends certified mail, return receipt requested, and I agree with his recommendation.
You can get an auto reply for delivered and a reply for read as well.
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Old 09-03-2017, 06:08 AM
 
1,793 posts, read 660,047 times
Reputation: 2983
Thank you everyone for the advice! There is a lot of good info here. I'll write those letters this weekend.

And just to clarify, I'm not saying the doctor and radiology department shouldn't be paid, I just think my insurance (which is currently paying $0) should pay the out of network percentage it says they pay in their program I'm enrolled in. I'm afraid if I pay in full first and expect a reimbursement from insurance later, I'll never get it. They are saying I should have chosen in network, but none of their facilities (my insurance has its own hospitals and such) are in the area where I was and no one knew how badly I was hurt other than I had crooked bones and I kept passing out. The idea that I shouldn't have gone to the nearest ER or that I should have spent time shopping around is nuts.
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Old 09-03-2017, 11:41 AM
 
Location: Florida
3,065 posts, read 2,353,700 times
Reputation: 2556
Quote:
Originally Posted by BellaLind View Post
Thank you everyone for the advice! There is a lot of good info here. I'll write those letters this weekend.

And just to clarify, I'm not saying the doctor and radiology department shouldn't be paid, I just think my insurance (which is currently paying $0) should pay the out of network percentage it says they pay in their program I'm enrolled in. I'm afraid if I pay in full first and expect a reimbursement from insurance later, I'll never get it. They are saying I should have chosen in network, but none of their facilities (my insurance has its own hospitals and such) are in the area where I was and no one knew how badly I was hurt other than I had crooked bones and I kept passing out. The idea that I shouldn't have gone to the nearest ER or that I should have spent time shopping around is nuts.
Agree
Another reason not to pay before a settlement is they should be more receptive to helping you with the insurance company.
You may need a bill with different medical codes or wording from them.
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