Hospital/medical bill - need advice

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squirm
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Hospital/medical bill - need advice

Post by squirm »

Brief update:
Early 2014 I visit my surgeon for possible surgery. He concludes I will need surgery. He is not in my health care network however, he has his own private practice. I accept to pay out of pocket for his services.
His office schedules the procedure with a hospital facility. His office forwards my insurance information to the facility and tells me the hospital is in my network.
One week before the procedure the hospital calls and informs me of my co-insurance which would be about $3000. I am ok with that, per my EOB.
The morning of the procedure the hospital gives me and my wife a written estimate of the procedure, again it's $3000. I give them my insurance card to copy.
I have the surgery.

Fast forward a month later, I'm getting a bill from the hospital for $15,000!! The hospital says I was actually in a different plan then the plan they thought I was in, which is true. They thought I was in plan A, but I'm in plan B, which they are not in my network.

At this point, something went very wrong, somebody made an error. Either the surgeon's office told them I was in Plan A, or the hospital assumed I was in Plan A, or something else happened.

I don't know what to do at this point. I shouldn't be responsible for this error, right? This is a lot of money. I have called my insurance provider, the rep agrees with me and has filed a appeal.

What should I be doing at this point? This problem has left me with sleepless nights worrying about this huge bill.
Thanks in advance.
mhalley
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Re: Hospital/medical bill - need advice

Post by mhalley »

I would recommend talking to Andrew Rubin who is an expert on health insurance. He has a website http://rubinhealth.com/
And takes calls on Doctor radio on thursdays at noon-2 pm est. At 1 877 nyudocs
Mike
toofache32
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Re: Hospital/medical bill - need advice

Post by toofache32 »

I have seen this happen a few times. The high school educated girl on the phone from the insurance company tells us that the hospital is in-network and even gives an authorization number. Her job is to always say "yes!" and never say no. My office will not schedule without an authorization number. The doctor's office is only as good as the information provided to them by the patient and/or the insurance company. On a few close calls, the hospital caught this before surgery and called to let us know. I recently had a case where the insurance company (UHC) repeatedly told my office scheduler that our hospital is in-network. The astute patient called the insurance company and was told they were not. It turns out the hospital does not participate in plans bought on the new healthcare marketplace for good reasons but the insurance card does not reveal to us how the plan was bought. A gap exception was submitted and approved and the patient was allowed to have their surgery.

Ultimately the patient is responsible for knowing the details of their insurance plan. If you want someone else to pay for it, then they have the right to make the rules. It's the PATIENT'S insurance, not the doctors or the hospitals. In a twisted way, I am glad this is becoming more common because the patients finally have skin in the game. Only when the customer (the patient) has skin in the game will they complain enough to make changes. On another note, I just dropped UHC and I am no longer an in-network provider. Complain loudly to your insurance company and don't let them dupe you into thinking the doctor or hospital dropped the ball because, again, all treatment is based on the information provided by the insurance company.
random_walker_77
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Re: Hospital/medical bill - need advice

Post by random_walker_77 »

So basically you're out of network and so don't have any sort of insurance-negotiated discounts. Understand that the way the health system works, the uninsured get charged 6-10x more. If you haven't seen it, there's a long article in Time (google for "time bitter pill") about the arbitrariness of pricing.

Document everything, lean on your insurance as a plan B, but plan on doing some major negotiating with the hospital. Don't panic just yet, and adjust your mindset: their number is the beginning of a negotiation. Also be aware that you may have multiple bills coming your way, not just from the hospital but also from your anesthesiologist. And nurses. And doctor(s) who may have checked on you during your visit. Your goal is to get the bill negotiated down 75+% so that it's close to what they'd get from an insured patient.

Keep in mind that they want to get paid too. Insurance is a PITA for the doctors and they don't get paid for a long time. Then again, the uninsured might not be able to pay or might go to collections for pennies on the dollar, so just keep in mind that "the other side" has incentives to negotiate. "cash customer discounts" and discounts for prompt payment are fairly standard.

I've no first hand experience, but google shows a lot of hits on "how to negotiate hospital bill without insurance"

Worst case, there are services where you can pay people to negotiate on your behalf.

Bottomline, get some sleep, adjust your mindset, and get ready for some negotiating. You'll want to do research. Good luck!
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squirm
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Re: Hospital/medical bill - need advice

Post by squirm »

Hello everyone. Thanks for the replies so far.
Random, I am insured, it's out of network though for Plan B. Plan B requires that I pay 40% of the costs with no cap. Plan A would require 40% of the costs too but with a $3000 cap.

The hospital based everything off me being in Plan A. I don't know where they got that information from. Perhaps the surgeons scheduler made a mistake when they booked the surgery date, or the hospital goofed.
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squirm
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Re: Hospital/medical bill - need advice

Post by squirm »

toofache32,
So far the insurances customer rep has been on the case. I plan on keeping the pressure on. Thank you for your reply.
investor1
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Re: Hospital/medical bill - need advice

Post by investor1 »

There are websites such as fairhealthconsumer.org where you can lookup typical hospital costs (there would be additional costs for the doctor, nurses, etc.) of specific proceedures based on things like medicare rates for your region. That might help you get an idea if you need to negoitate a bill.
smithysmithy
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Re: Hospital/medical bill - need advice

Post by smithysmithy »

squirm,

I don't really have any advice, but you might find this article and accompanying comments helpful: http://www.nytimes.com/2014/09/21/us/dr ... -bills.htm

Also, this thread covers similar issues: viewtopic.php?f=2&t=122604

This whole "out of network" business scares the heck out of me. Best of luck to you.
bluemarlin08
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Re: Hospital/medical bill - need advice

Post by bluemarlin08 »

I had something similar happen 2 years ago. I scheduled a meeting with the manager of customer relations at the hospital. They reduced the bill to my max out of pocket in network and they went after the insurance company.
toofache32
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Re: Hospital/medical bill - need advice

Post by toofache32 »

squirm wrote:Hello everyone. Thanks for the replies so far.
Random, I am insured, it's out of network though for Plan B. Plan B requires that I pay 40% of the costs with no cap. Plan A would require 40% of the costs too but with a $3000 cap.

The hospital based everything off me being in Plan A. I don't know where they got that information from. Perhaps the surgeons scheduler made a mistake when they booked the surgery date, or the hospital goofed.
What about the insurance company? Why are they not on your list of people that could have made an error? Interesting how nobody ever considers that the insurance companies could be the ones who made the mistake. Surprisingly, it's sometimes intentional. The insurance companies are not our friends.
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squirm
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Re: Hospital/medical bill - need advice

Post by squirm »

Guys, thanks for the info.
Sounds like there are a few ways to raise this issue. Not only to the insurance, but to the hospital too. However, doesn't the surgeon's office have a role in this? They could have been the entity that provided the wrong information to the hospital.

Second, are there things I shouldn't be doing? I don't want to dig myself a deeper hole. I have an apt with the admin at the surgeon's office to let them know what is going on. I'm not sure what their response will be.
Last edited by squirm on Thu Feb 05, 2015 8:29 am, edited 1 time in total.
dolphinsaremammals
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Re: Hospital/medical bill - need advice

Post by dolphinsaremammals »

This really is a mine field. I remember years ago calling a hospital to find out the cost of a catscan, I think it was, in case it would be coming out of my pocket. I got told $X. It was actually 2x$X because it was done once additionally with contrast. The people who give quotes over the phone and similar information are clueless. This is one reason why we need universal complete health coverage.
adamthesmythe
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Re: Hospital/medical bill - need advice

Post by adamthesmythe »

> Second, are there things I shouldn't be doing?

(in my opinion) you shouldn't pay. And be prepared for this to take LONG time. Maybe you will be lucky, but it might take a year to work out.
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gasdoc
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Re: Hospital/medical bill - need advice

Post by gasdoc »

Generally, the initial insurance info comes from the surgeon's office when they call the hospital to schedule the case in the OR. However, the hospital registration department then takes their own info. When you went to the hospital for a quote, did you give them the insurance info in writing? That is where the mis-comminication probably happened. Legally, you received a service and the hospital has a right to be paid. I am assuming you would have chosen a different hospital had you known you would be treated as out of network? In any case, you are now at the mercy of the hospital- so I would go to them, explain the situation, agree with them that you owe them for the services rendered (hat in hand), and ask them for help with the bill. As an anesthesiologist, in my experience, they should at a minimum give you the insurance negotiated rates. The problem will be that the insurance company does not have an obligation to pay the insurance part of the bill becuase you have not paid the premium that would have allowed that. So- the hospital will be out the entire insurance portion if it is not paid by you. I would negotiate for the hospital to drop a portion of that part of the bill, and to bill you at the insurance company rates for the remaining portion. Like with any other company, let them know that you love their hospital, and that you always use that hospital, and that you would love to continue using and recommending that hospital in the future, especially if they are helpful in this problem.
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gasdoc
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Re: Hospital/medical bill - need advice

Post by gasdoc »

adamthesmythe wrote:> Second, are there things I shouldn't be doing?

(in my opinion) you shouldn't pay. And be prepared for this to take LONG time. Maybe you will be lucky, but it might take a year to work out.
This should not take a year. If you simply do not pay, you will find yourself turned over to collections, and although at some point you will get your bill reduced, it will trash your credit (as it should, since you would have simply defaulted on a bill). This should be negotiated in a friendly way with the hospital immediately (IMO).
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squirm
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Re: Hospital/medical bill - need advice

Post by squirm »

bkinder wrote:Generally, the initial insurance info comes from the surgeon's office when they call the hospital to schedule the case in the OR. However, the hospital registration department then takes their own info. When you went to the hospital for a quote, did you give them the insurance info in writing? That is where the mis-comminication probably happened. Legally, you received a service and the hospital has a right to be paid. I am assuming you would have chosen a different hospital had you known you would be treated as out of network? In any case, you are now at the mercy of the hospital- so I would go to them, explain the situation, agree with them that you owe them for the services rendered (hat in hand), and ask them for help with the bill. As an anesthesiologist, in my experience, they should at a minimum give you the insurance negotiated rates. The problem will be that the insurance company does not have an obligation to pay the insurance part of the bill becuase you have not paid the premium that would have allowed that. So- the hospital will be out the entire insurance portion if it is not paid by you. I would negotiate for the hospital to drop a portion of that part of the bill, and to bill you at the insurance company rates for the remaining portion. Like with any other company, let them know that you love their hospital, and that you always use that hospital, and that you would love to continue using and recommending that hospital in the future, especially if they are helpful in this problem.
The surgeons office told me this hospital was a "preferred provider" a month before the surgery. As it turns out, they were not a "preferred provider" The surgeons office had my insurance card on file.
The written estimate I received from the hospital was the morning of the surgery at 5am. That is when they took my insurance card too.
I received a verbal quote about a week prior from the hospital...both quotes were for $3000 for the co-insurance portion, which I was fine with.

I would have gone to another provider for sure, if I knew this was taking place.

I have to have another surgery on my other side this year, I would love it if I could use the same facility and surgeon, I was very happy with everything. I have much better insurance this year so this won't be an issue.
Last edited by squirm on Thu Feb 05, 2015 11:01 am, edited 1 time in total.
Topic Author
squirm
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Re: Hospital/medical bill - need advice

Post by squirm »

bkinder wrote:
adamthesmythe wrote:> Second, are there things I shouldn't be doing?

(in my opinion) you shouldn't pay. And be prepared for this to take LONG time. Maybe you will be lucky, but it might take a year to work out.
This should not take a year. If you simply do not pay, you will find yourself turned over to collections, and although at some point you will get your bill reduced, it will trash your credit (as it should, since you would have simply defaulted on a bill). This should be negotiated in a friendly way with the hospital immediately (IMO).
Currently the insurance is appealing it. The insurance rep said if it doesn't go in my favor, I could appeal a second time, however the second appeal needs to have "new information". I'm not sure what that would be at this point.
johnubc
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Re: Hospital/medical bill - need advice

Post by johnubc »

Ultimately, you are the one responsible for the bill - and also for verifying your own coverage. Everytime I need something, I validate that the recommended provider is included in my plan. The games that are played all in an effort to not pay is enormous.

The next part of the game is the anesthesiologist who likely will belong to no plan - and is assigned to you based on the hospitals relationship with their practice. I think if an in-network provider is scheduling services for me, they should be required to use in-network services.
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Re: Hospital/medical bill - need advice

Post by nisiprius »

The only useful thing I have to contribute is that many states have something generically known as an "ombudsmans' office for health insurance." Call up the most relevant number you can find and keep asking about the "health insurance ombudsman" until you find someone who seems to know what you are talking about and can say "Oh, yes, you mean the WinnemacHealth Division of Health Insurance Policyholder Advocacy or 'Whipplepffft' as we call it." Then tell them the story. I had one experience and after getting a really complicated runaround for three weeks, I called them in the morning and they had resolved the issue that afternoon. Your mileage may vary.
toofache32 wrote:...Ultimately the patient is responsible for knowing the details of their insurance plan....
You have just touched off a burst of wild, impotent insane fury on my part. Insert language not permitted on the forum here. You are blaming the victim. Those of us who are careful, cautious, responsible people are getting unfairly hit by things that are outside of our control.

The sad fact is that there IS no way to know the details of your insurance plan.

Them's the facts, anything else is theory.

You hear voices on the phone. You can't get anything in writing. Voices on the phone today tell you that the voices you heard on the phone yesterday couldn't possibly have said the things you said, even though you made written notes.

Just one trivial detail. Have you ever tried to get an actual copy of the actual contract? This may be a decade out of date but I have tried several times and failed. The insurance company always gives a condescending laugh and says, "Oh, that's hundreds of pages long." And I say "Great, send me the hundreds of pages." Pause. "And you couldn't understand it anyway." And I say "Fine, I can't understand it, but I want it anyway." And they say, politely but evasively, that I can't have it. (As I recall, one explanation was that no two of their employers' plans were identical and that they couldn't release the actual contract because the specific plan details were a secret confidential business deal).
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random_walker_77
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Re: Hospital/medical bill - need advice

Post by random_walker_77 »

squirm wrote:Hello everyone. Thanks for the replies so far.
Random, I am insured, it's out of network though for Plan B. Plan B requires that I pay 40% of the costs with no cap.
Yes, I understand, but b/c you're not in-network, and hence don't have the advantage of pre-negotiated discounts, your mindset should be as if you have no insurance. Keep in mind that, technically, you could take the bill, pay it, and submit it for reimbursement to your insurance directly. Providers often work with your insurance directly "as a courtesy," which does save you lots of time and aggravation. (As I understand it, doctors and hospitals maintain a staff dedicated to handling massive insurance paperwork).

But my main point is that you could negotiate it down, pay it, and then work with your insurance for reimbursement. I don't necessarily recommend this, but I think this is the mindset you want to take into the negotiations. Again, insurance companies get 75-90% discounts negotiated. That's what you get by going in-network. Here, you need to do your own negotiating. Almost no one pays the full sticker price, and you need to try and get that 80% discount.

Also, you have one major advantage -- you know what the negotiated pricetag under Plan A is. This is nonpublic information. In fact, I've heard the insurance companies consider it to be confidential and proprietary, since it's the outcome of *their* negotiations w/ the medical provider. They have scale. You have the threat that the hospital might get $0 from you. The hospital has the ability to hurt your credit record for the next 7 years, and to decline to work with you on the next surgery (if they know about it).

Next time around, shop around, and try to do all the negotiating beforehand... (but the opacity of pricing makes this hard)
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Wildebeest
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Re: Hospital/medical bill - need advice

Post by Wildebeest »

nisiprius wrote:The only useful thing I have to contribute is that many states have something generically known as an "ombudsmans' office for health insurance." Call up the most relevant number you can find and keep asking about the "health insurance ombudsman" until you find someone who seems to know what you are talking about and can say "Oh, yes, you mean the WinnemacHealth Division of Health Insurance Policyholder Advocacy or 'Whipplepffft' as we call it." Then tell them the story. I had one experience and after getting a really complicated runaround for three weeks, I called them in the morning and they had resolved the issue that afternoon. Your mileage may vary.
toofache32 wrote:...Ultimately the patient is responsible for knowing the details of their insurance plan....
You have just touched off a burst of wild, impotent insane fury on my part. Insert language not permitted on the forum here. You are blaming the victim. Those of us who are careful, cautious, responsible people are getting unfairly hit by things that are outside of our control.

The sad fact is that there IS no way to know the details of your insurance plan.

Them's the facts, anything else is theory.

You hear voices on the phone. You can't get anything in writing. Voices on the phone today tell you that the voices you heard on the phone yesterday couldn't possibly have said the things you said, even though you made written notes.

Just one trivial detail. Have you ever tried to get an actual copy of the actual contract? This may be a decade out of date but I have tried several times and failed. The insurance company always gives a condescending laugh and says, "Oh, that's hundreds of pages long." And I say "Great, send me the hundreds of pages." Pause. "And you couldn't understand it anyway." And I say "Fine, I can't understand it, but I want it anyway." And they say, politely but evasively, that I can't have it. (As I recall, one explanation was that no two of their employers' plans were identical and that they couldn't release the actual contract because the specific plan details were a secret confidential business deal).
I wholeheartedly agree with Nisiprius on this. Nisi's advice to go to the "health insurance ombudsman" is golden.

I feel terrible for the OP, that he does everything right and still ends up with a $15,000 bill. Then the insurance company, the hospital and the doctor's office start pointing fingers at each other and the patient holds the bag. The OP appears to be resourceful, and well informed. Imagine somebody trying to deal with the health system, when you are not that fortunate. Someone, who is sick and financially stressed, has a small chance of getting out with their hide.

I do find it interesting, that the OP blamed the "care providers" for not knowing his insurance's arbitrary rules and exclusions. Health insurance is the 800 lbs gorilla, which makes money by denying care in any way they can get away with.

IMHO healthinsurance company policies are more despicable than that of the "whole life annuity" business. Being sold whole life annuity at free dinner presentation is optional and for the well heeled, but everybody needs health insurance.
Last edited by Wildebeest on Thu Feb 05, 2015 11:36 am, edited 1 time in total.
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squirm
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Re: Hospital/medical bill - need advice

Post by squirm »

random_walker_77 wrote:
squirm wrote:Hello everyone. Thanks for the replies so far.
Random, I am insured, it's out of network though for Plan B. Plan B requires that I pay 40% of the costs with no cap.
Yes, I understand, but b/c you're not in-network, and hence don't have the advantage of pre-negotiated discounts, your mindset should be as if you have no insurance. Keep in mind that, technically, you could take the bill, pay it, and submit it for reimbursement to your insurance directly. Providers often work with your insurance directly "as a courtesy," which does save you lots of time and aggravation. (As I understand it, doctors and hospitals maintain a staff dedicated to handling massive insurance paperwork).

But my main point is that you could negotiate it down, pay it, and then work with your insurance for reimbursement. I don't necessarily recommend this, but I think this is the mindset you want to take into the negotiations. Again, insurance companies get 75-90% discounts negotiated. That's what you get by going in-network. Here, you need to do your own negotiating. Almost no one pays the full sticker price, and you need to try and get that 80% discount.

Also, you have one major advantage -- you know what the negotiated pricetag under Plan A is. This is nonpublic information. In fact, I've heard the insurance companies consider it to be confidential and proprietary, since it's the outcome of *their* negotiations w/ the medical provider. They have scale. You have the threat that the hospital might get $0 from you. The hospital has the ability to hurt your credit record for the next 7 years, and to decline to work with you on the next surgery (if they know about it).

Next time around, shop around, and try to do all the negotiating beforehand... (but the opacity of pricing makes this hard)

This is off the main topic, I currently have a claim with my insurance to reimburse me for the surgeon fee's since I paid out of pocket for his services. I paid $3100. The insurance in theory is suppose to reimburse me 50% of the "allowed amount" which will probably be 50% of $1800. My surgeon said he doesn't take my insurance because the reimbursement rate is so low...However this is a separate item from the real issue which is the provider fee's.

Back to the main topic. So you're saying that the 40% of my co-insurance (Plan B that has no cap) actually could count as me not being insured and I could make a claim to get reimbursed from that. I will look into that. That sounds similar to what I'm currently doing with my surgeon fees as described above.

When I spoke to my insurance they told me that the provider submitted the bill to them. The provider (the hospital) submitted roughly a $33,000 bill. Per my Plan B, the insurance paid 60% of that. The provider therefore charged me with the remaining 40% or about $15,000. If I understand this correctly, I can negotiate the $15,000 bill with the hospital and (hopefully get it reduced) and the remaining amount that I pay to the hospital I can submit to the insurance in hopes of getting a reimbursement?

I also did want to throw this out there again, what role does my surgeons office have in this? They scheduled the surgery and date. They told me the provider was a In Network provider with the insurance I had. I have an apt with the admin person tomorrow to discuss this and would like to prepare some pertinent questions. I really like my surgeon and his staff, they've been remarkable for my care so I will keep very civil.
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Re: Hospital/medical bill - need advice

Post by bluemarlin08 »

I had an additional situation last year when I visited my cardiologist for an exam, located in the same building of a large out of network hospital but he is in network. He performed an EKG and discovered I was in Atrial Fib. He insisted on admitting me to the hospital. I told him the hospital was out of network and would need to go to another facility. He excused himself for a moment then returned and told me he spoke with the hospital administrator's office and they would accept me and only charge in network rates. After the stay I received a huge bill and contacted the facility and they said they had no record of this arrangement. Had to get the doctors office to work it out. I could go on and on about these episodes.
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squirm
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Re: Hospital/medical bill - need advice

Post by squirm »

nisiprius wrote:The only useful thing I have to contribute is that many states have something generically known as an "ombudsmans' office for health insurance." Call up the most relevant number you can find and keep asking about the "health insurance ombudsman" until you find someone who seems to know what you are talking about and can say "Oh, yes, you mean the WinnemacHealth Division of Health Insurance Policyholder Advocacy or 'Whipplepffft' as we call it." Then tell them the story.

Thank you for that. My thought is to try and deal with this myself and if I don't seem to be making any headway I will look into an advocate. I don't know at this point if an attorney would be better or to go the route your suggesting.
Thanks for the input.
adamthesmythe
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Re: Hospital/medical bill - need advice

Post by adamthesmythe »

> This should not take a year. If you simply do not pay, you will find yourself turned over to collections, and although at some point you will get your bill reduced, it will trash your credit (as it should, since you would have simply defaulted on a bill). This should be negotiated in a friendly way with the hospital immediately (IMO).

I'm not saying OP shouldn't attempt to negotiate immediately; I am suggesting that he has no leverage at all after he pays the bill.
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Re: Hospital/medical bill - need advice

Post by likegarden »

Last year my wife and I had colonoscopies. Then I had cataract surgery on both eyes. Initially we verified with the insurance companies that they cover these procedures. Every time we looked through a big book from our insurance company (Blue Shield) and verified that doctors, hospital and clinic were in-plan. When we signed in at hospital and clinic our insurance cards were copied, which means these facilities and doctors then knew our insurance plans. At the hospital we did not sign a paragraph that doctors may send us their bills, but wrote in that all bills have to go to the insurance company because we have an HMO plan. All surgeries and financials went fine.
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gasdoc
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Re: Hospital/medical bill - need advice

Post by gasdoc »

This is all very convoluted, with a lot of verbal commitments and not much in writing. Unfortunately, it is the hospital bill that is at stake, and the only negotiations that really matter are with the hospital. If the surgeon brings a lot of cases to this particular hospital, he may have some influence there. The insurance company will have no influence, and likely will not negotiate with you about paying for a bill they legally do not have to pay. As I said before, your only real discourse will be to sit down with a hospital representative and find out what they are willing to do for you. By the way, I am an anesthesiologist, and I am in network for all patients that are attracted to my particular hospital, and am a little annoyed at a previous poster that made an erroneous assumption. I no longer own my own group, but when I did, when things like this happened, and I was contacted, I was quick to reduce the bill down to what insurance would have paid out of fairness. But that's just me.
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squirm
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Re: Hospital/medical bill - need advice

Post by squirm »

BK,
From my understanding the surgeon doesn't normally operate out of this hospital, he's well known but most of his surgeries take place in another city.

When I speak or have a meeting with the hospital, who do I confer with or who do I ask to meet? Certainly it's not with the person behind the desk. Should I present some sort of timeline, such as all this has happened, starting with my initial visit to the surgeons office and the possibility that his staff might have informed the hospital about me having the wrong plan?
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Re: Hospital/medical bill - need advice

Post by fposte »

squirm wrote:
nisiprius wrote:The only useful thing I have to contribute is that many states have something generically known as an "ombudsmans' office for health insurance." Call up the most relevant number you can find and keep asking about the "health insurance ombudsman" until you find someone who seems to know what you are talking about and can say "Oh, yes, you mean the WinnemacHealth Division of Health Insurance Policyholder Advocacy or 'Whipplepffft' as we call it." Then tell them the story.

Thank you for that. My thought is to try and deal with this myself and if I don't seem to be making any headway I will look into an advocate. I don't know at this point if an attorney would be better or to go the route your suggesting.
In my state (Illinois) the equivalent of this is part of the attorney general's office, and it seems to have a fair bit of weight; I suspect it might get you better results than a private lawyer who doesn't have leverage without you paying for it.
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gasdoc
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Re: Hospital/medical bill - need advice

Post by gasdoc »

squirm wrote:BK,
From my understanding the surgeon doesn't normally operate out of this hospital, he's well known but most of his surgeries take place in another city.

When I speak or have a meeting with the hospital, who do I confer with or who do I ask to meet? Certainly it's not with the person behind the desk. Should I present some sort of timeline, such as all this has happened, starting with my initial visit to the surgeons office and the possibility that his staff might have informed the hospital about me having the wrong plan?
1) The surgeon will probably not be helpful since he does not bring much money to the hospital- sorry, but that is how that works.
2) I would probably call the main hospital number, and ask for a manager in the billing department- then set up an appointment to meet with him/her in person. I would lay it all out there- blame anyone you want, but not the hospital. You can relay how the hospital employee gave you bad information- but do it in a way that makes you a victim they will sympathize with rather than get defensive. Again, reinforce the idea that you do not blame them. Another poster mentioned an attorney or a government health care regulator of some sort. I would not go this route- that will only make the hospital representative walk away from the table and rely strictly on the contract between you and the hospital. In other words, they will want to do everything by the book if lawyers are involved, and remember, at some point you signed a contract agreeing to be responsible for the entire bill, even if the insurance company does not pay. That is a standard contract between you and every health care provider- you are ultimately responsible for the entire bill. I would acknowledge that, and go from there. The difference between the hospital and the insurance company in this regard is that the hospital wants your business and that of your family and friends in the future, especially since you just said you now have better insurance. On the other hand, the more you use their product, the less the insurance company wants anything to do with you!!!! :confused Please let me know it goes. :happy
ikowik
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Re: Hospital/medical bill - need advice

Post by ikowik »

bkinder wrote:
squirm wrote:BK,
From my understanding the surgeon doesn't normally operate out of this hospital, he's well known but most of his surgeries take place in another city.

When I speak or have a meeting with the hospital, who do I confer with or who do I ask to meet? Certainly it's not with the person behind the desk. Should I present some sort of timeline, such as all this has happened, starting with my initial visit to the surgeons office and the possibility that his staff might have informed the hospital about me having the wrong plan?
1) The surgeon will probably not be helpful since he does not bring much money to the hospital- sorry, but that is how that works.
2) I would probably call the main hospital number, and ask for a manager in the billing department- then set up an appointment to meet with him/her in person. I would lay it all out there- blame anyone you want, but not the hospital. You can relay how the hospital employee gave you bad information- but do it in a way that makes you a victim they will sympathize with rather than get defensive. Again, reinforce the idea that you do not blame them. Another poster mentioned an attorney or a government health care regulator of some sort. I would not go this route- that will only make the hospital representative walk away from the table and rely strictly on the contract between you and the hospital. In other words, they will want to do everything by the book if lawyers are involved, and remember, at some point you signed a contract agreeing to be responsible for the entire bill, even if the insurance company does not pay. That is a standard contract between you and every health care provider- you are ultimately responsible for the entire bill. I would acknowledge that, and go from there. The difference between the hospital and the insurance company in this regard is that the hospital wants your business and that of your family and friends in the future, especially since you just said you now have better insurance. On the other hand, the more you use their product, the less the insurance company wants anything to do with you!!!! :confused Please let me know it goes. :happy
I get the feeling I am missing something, somebody explain this to me.
The hospital took OP's insurance card, so they have the correct plan information.
Then they give him a written estimate for $3000 based on that information.
Now the hospital says the information on which they estimated OP's cost is wrong---in effect saying that they made an error in reading OP's insurance card.
Is this not an error on the hospital's part, and how does one NOT blame the hospital when negotiating with them?
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squirm
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Re: Hospital/medical bill - need advice

Post by squirm »

ikowik wrote:
bkinder wrote:
squirm wrote:BK,
From my understanding the surgeon doesn't normally operate out of this hospital, he's well known but most of his surgeries take place in another city.

When I speak or have a meeting with the hospital, who do I confer with or who do I ask to meet? Certainly it's not with the person behind the desk. Should I present some sort of timeline, such as all this has happened, starting with my initial visit to the surgeons office and the possibility that his staff might have informed the hospital about me having the wrong plan?

I get the feeling I am missing something, somebody explain this to me.
The hospital took OP's insurance card, so they have the correct plan information.
Then they give him a written estimate for $3000 based on that information.
Now the hospital says the information on which they estimated OP's cost is wrong---in effect saying that they made an error in reading OP's insurance card.
Is this not an error on the hospital's part, and how does one NOT blame the hospital when negotiating with them?
Yes....The surgeons office took my insurance card made copies of it at least a month or two before my surgery. The surgeons office told me the hospital is in network. A week before the surgery, the hospital called, went over what to do and not do regarding taking pills etc and then said my cost would be $3000. The morning of the surgery the hospital took my insurance card made copies of it and gave me a written estimate of $3000 about an hour before I went under.

Hospital is now billing me thousands more because I was not in the insurance plan that they based their estimate on.
Last edited by squirm on Thu Feb 05, 2015 7:25 pm, edited 1 time in total.
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Re: Hospital/medical bill - need advice

Post by squirm »

bkinder wrote:
squirm wrote:BK,


1) The surgeon will probably not be helpful since he does not bring much money to the hospital- sorry, but that is how that works.
2) I would probably call the main hospital number, and ask for a manager in the billing department- then set up an appointment to meet with him/her in person. I would lay it all out there- blame anyone you want, but not the hospital. You can relay how the hospital employee gave you bad information- but do it in a way that makes you a victim they will sympathize with rather than get defensive. Again, reinforce the idea that you do not blame them. Another poster mentioned an attorney or a government health care regulator of some sort. I would not go this route- that will only make the hospital representative walk away from the table and rely strictly on the contract between you and the hospital. In other words, they will want to do everything by the book if lawyers are involved, and remember, at some point you signed a contract agreeing to be responsible for the entire bill, even if the insurance company does not pay. That is a standard contract between you and every health care provider- you are ultimately responsible for the entire bill. I would acknowledge that, and go from there. The difference between the hospital and the insurance company in this regard is that the hospital wants your business and that of your family and friends in the future, especially since you just said you now have better insurance. On the other hand, the more you use their product, the less the insurance company wants anything to do with you!!!! :confused Please let me know it goes. :happy
Thank you. It sounds like the best way to play this to the hospital is to place blame on the surgeons office, which is probably where it falls anyways.
toofache32
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Re: Hospital/medical bill - need advice

Post by toofache32 »

squirm wrote:
random_walker_77 wrote:
squirm wrote:Hello everyone. Thanks for the replies so far.
Random, I am insured, it's out of network though for Plan B. Plan B requires that I pay 40% of the costs with no cap.
Yes, I understand, but b/c you're not in-network, and hence don't have the advantage of pre-negotiated discounts, your mindset should be as if you have no insurance. Keep in mind that, technically, you could take the bill, pay it, and submit it for reimbursement to your insurance directly. Providers often work with your insurance directly "as a courtesy," which does save you lots of time and aggravation. (As I understand it, doctors and hospitals maintain a staff dedicated to handling massive insurance paperwork).

But my main point is that you could negotiate it down, pay it, and then work with your insurance for reimbursement. I don't necessarily recommend this, but I think this is the mindset you want to take into the negotiations. Again, insurance companies get 75-90% discounts negotiated. That's what you get by going in-network. Here, you need to do your own negotiating. Almost no one pays the full sticker price, and you need to try and get that 80% discount.

Also, you have one major advantage -- you know what the negotiated pricetag under Plan A is. This is nonpublic information. In fact, I've heard the insurance companies consider it to be confidential and proprietary, since it's the outcome of *their* negotiations w/ the medical provider. They have scale. You have the threat that the hospital might get $0 from you. The hospital has the ability to hurt your credit record for the next 7 years, and to decline to work with you on the next surgery (if they know about it).

Next time around, shop around, and try to do all the negotiating beforehand... (but the opacity of pricing makes this hard)

This is off the main topic, I currently have a claim with my insurance to reimburse me for the surgeon fee's since I paid out of pocket for his services. I paid $3100. The insurance in theory is suppose to reimburse me 50% of the "allowed amount" which will probably be 50% of $1800. My surgeon said he doesn't take my insurance because the reimbursement rate is so low...However this is a separate item from the real issue which is the provider fee's.

Back to the main topic. So you're saying that the 40% of my co-insurance (Plan B that has no cap) actually could count as me not being insured and I could make a claim to get reimbursed from that. I will look into that. That sounds similar to what I'm currently doing with my surgeon fees as described above.

When I spoke to my insurance they told me that the provider submitted the bill to them. The provider (the hospital) submitted roughly a $33,000 bill. Per my Plan B, the insurance paid 60% of that. The provider therefore charged me with the remaining 40% or about $15,000. If I understand this correctly, I can negotiate the $15,000 bill with the hospital and (hopefully get it reduced) and the remaining amount that I pay to the hospital I can submit to the insurance in hopes of getting a reimbursement?

I also did want to throw this out there again, what role does my surgeons office have in this? They scheduled the surgery and date. They told me the provider was a In Network provider with the insurance I had. I have an apt with the admin person tomorrow to discuss this and would like to prepare some pertinent questions. I really like my surgeon and his staff, they've been remarkable for my care so I will keep very civil.
toofache32
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Re: Hospital/medical bill - need advice

Post by toofache32 »

nisiprius wrote:
toofache32 wrote:...Ultimately the patient is responsible for knowing the details of their insurance plan....
You have just touched off a burst of wild, impotent insane fury on my part. Insert language not permitted on the forum here. You are blaming the victim. Those of us who are careful, cautious, responsible people are getting unfairly hit by things that are outside of our control.

The sad fact is that there IS no way to know the details of your insurance plan.

Them's the facts, anything else is theory.

You hear voices on the phone. You can't get anything in writing. Voices on the phone today tell you that the voices you heard on the phone yesterday couldn't possibly have said the things you said, even though you made written notes.

Just one trivial detail. Have you ever tried to get an actual copy of the actual contract? This may be a decade out of date but I have tried several times and failed. The insurance company always gives a condescending laugh and says, "Oh, that's hundreds of pages long." And I say "Great, send me the hundreds of pages." Pause. "And you couldn't understand it anyway." And I say "Fine, I can't understand it, but I want it anyway." And they say, politely but evasively, that I can't have it. (As I recall, one explanation was that no two of their employers' plans were identical and that they couldn't release the actual contract because the specific plan details were a secret confidential business deal).
I agree with everything you said except when you say the patient is the victim. The doctor is also the victim because he and his employees now risks not getting paid. The doctor's office has the same conversations and frustrations with the insurance company. Many people think the doctors are "in cahoots" with the insurance companies for some reason. Again, the insurance companies are not anyone's friend, despite their marketing efforts that say otherwise.
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Re: Hospital/medical bill - need advice

Post by toofache32 »

johnubc wrote:Ultimately, you are the one responsible for the bill - and also for verifying your own coverage. Everytime I need something, I validate that the recommended provider is included in my plan. The games that are played all in an effort to not pay is enormous.

The next part of the game is the anesthesiologist who likely will belong to no plan - and is assigned to you based on the hospitals relationship with their practice. I think if an in-network provider is scheduling services for me, they should be required to use in-network services.
The provider has no way of knowing what hospitals are in-network as this changes weekly and their are literally hundreds of plans out there. BCBS for example has over 20 plans in my area. Multiply this by Aetna, Cigna, UHC, Metlife, and all the others. The doctor's office has to call the hospital and insurance every time to verify since this changes often. Again, the doctor does not own the policy, the PATIENT owns the policy and ultimately has the final responsibility.
toofache32
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Re: Hospital/medical bill - need advice

Post by toofache32 »

squirm wrote:
I also did want to throw this out there again, what role does my surgeons office have in this? They scheduled the surgery and date. They told me the provider was a In Network provider with the insurance I had. I have an apt with the admin person tomorrow to discuss this and would like to prepare some pertinent questions. I really like my surgeon and his staff, they've been remarkable for my care so I will keep very civil.
The surgeon's office is merely passing along the message to you that the insurance company said they were in-network. Their information is only as good as what the insurance company tells them.
toofache32
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Re: Hospital/medical bill - need advice

Post by toofache32 »

squirm wrote:
bkinder wrote:
squirm wrote:BK,


1) The surgeon will probably not be helpful since he does not bring much money to the hospital- sorry, but that is how that works.
2) I would probably call the main hospital number, and ask for a manager in the billing department- then set up an appointment to meet with him/her in person. I would lay it all out there- blame anyone you want, but not the hospital. You can relay how the hospital employee gave you bad information- but do it in a way that makes you a victim they will sympathize with rather than get defensive. Again, reinforce the idea that you do not blame them. Another poster mentioned an attorney or a government health care regulator of some sort. I would not go this route- that will only make the hospital representative walk away from the table and rely strictly on the contract between you and the hospital. In other words, they will want to do everything by the book if lawyers are involved, and remember, at some point you signed a contract agreeing to be responsible for the entire bill, even if the insurance company does not pay. That is a standard contract between you and every health care provider- you are ultimately responsible for the entire bill. I would acknowledge that, and go from there. The difference between the hospital and the insurance company in this regard is that the hospital wants your business and that of your family and friends in the future, especially since you just said you now have better insurance. On the other hand, the more you use their product, the less the insurance company wants anything to do with you!!!! :confused Please let me know it goes. :happy
Thank you. It sounds like the best way to play this to the hospital is to place blame on the surgeons office, which is probably where it falls anyways.
:oops:
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gasdoc
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Re: Hospital/medical bill - need advice

Post by gasdoc »

I understand the confusion- it is not much better for the providers. I think one point of confusion lies in the fact that the OP gave the surgeon and the hospital his insurance card. I looked at my insurance card just a moment ago. It has a couple of group and policy numbers. All that card does is tells the providers who to send the bill to, and how to identify the patient to the insurance company. It does not actually list any particular coverages. It may also list deductibles and copays, but only very generally. The provider has to take it on faith that 1) the insurance premiums have been paid and the policy is still in effect, and 2) that the policy actually covers the intended procedure. Again, as other posters have indicated, the actual contract is between the provider and the patient, as it should be. When the provider takes the card, and attempts to collect from the insurance company, it is actually doing the patient a favor (well, actually, this may be the only money the provider may get! :( ). The written estimate, I am sure it must have said on the sheet, was non-binding, and based only on the information the hospital had on hand at the time. The actual written contract was in the stack of other papers the patient signs- again, the one that says the patient is responsible for the entire bill. Your only recourse, again, is to negotiate in good faith with the hospital.
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Re: Hospital/medical bill - need advice

Post by Impromptu »

I have found the opacity in billing is one of the most frustrating parts of medicine. The main cost reduction mechanisms in Obamacare is to severely limit access to medical care after the initial increase in insurance coverage. This is done by limiting the number of providers and facilities you are allowed to see under your plan. If you could see anyone you wanted at any location, then usage of medical care would increase, which would increase cost. If you bottleneck the cheaper plans to only a few doctors and hospitals, then it will take longer for those patients to get care and thus limit costs. To further reduce costs, once the patients feel the sting of paying for their own care, they will be more hesitant to use it next time.
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gasdoc
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Re: Hospital/medical bill - need advice

Post by gasdoc »

Impromptu wrote:I have found the opacity in billing is one of the most frustrating parts of medicine. The main cost reduction mechanisms in Obamacare is to severely limit access to medical care after the initial increase in insurance coverage. This is done by limiting the number of providers and facilities you are allowed to see under your plan. If you could see anyone you wanted at any location, then usage of medical care would increase, which would increase cost. If you bottleneck the cheaper plans to only a few doctors and hospitals, then it will take longer for those patients to get care and thus limit costs. To further reduce costs, once the patients feel the sting of paying for their own care, they will be more hesitant to use it next time.

It is frustrating. Even the physicians cannot find out the true costs for hospital supples, etc. This is off topic, but I discovered a great app for buying meds for people that do not have drug coverage (like myself). Goodrx.com. It quickly shows negotiated discount drug costs at local pharmacies. :sharebeer
random_walker_77
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Re: Hospital/medical bill - need advice

Post by random_walker_77 »

squirm wrote:
This is off the main topic, I currently have a claim with my insurance to reimburse me for the surgeon fee's since I paid out of pocket for his services. I paid $3100. The insurance in theory is suppose to reimburse me 50% of the "allowed amount" which will probably be 50% of $1800. My surgeon said he doesn't take my insurance because the reimbursement rate is so low...However this is a separate item from the real issue which is the provider fee's.
Again, there's the sticker price and then there's the price that is typically paid (b/c of negotiated discounts). Your bill is for $3100. In-network, your insurance would get a big discount. They consider $1800 to be typical, and so they'll pay 50% of that. Your job is to negotiate the main bill down under $2000. (or come up w/ evidence that $1800 is unrealistically low for that procedure in your area).
squirm wrote: Back to the main topic. So you're saying that the 40% of my co-insurance (Plan B that has no cap) actually could count as me not being insured and I could make a claim to get reimbursed from that. I will look into that. That sounds similar to what I'm currently doing with my surgeon fees as described above.
I'm suggesting that you're getting a 0% discount. Your objective is to negotiate a discount away from the unrealistic sticker price. Then you split the bill w/ insurance 40/60 as per your policy.
squirm wrote: When I spoke to my insurance they told me that the provider submitted the bill to them. The provider (the hospital) submitted roughly a $33,000 bill. Per my Plan B, the insurance paid 60% of that. The provider therefore charged me with the remaining 40% or about $15,000. If I understand this correctly, I can negotiate the $15,000 bill with the hospital and (hopefully get it reduced) and the remaining amount that I pay to the hospital I can submit to the insurance in hopes of getting a reimbursement?

I also did want to throw this out there again, what role does my surgeons office have in this? They scheduled the surgery and date. They told me the provider was a In Network provider with the insurance I had. I have an apt with the admin person tomorrow to discuss this and would like to prepare some pertinent questions. I really like my surgeon and his staff, they've been remarkable for my care so I will keep very civil.
You know that this $33K bill would've been paid out at $7.5K, whereupon your 40% would come out to $3K. That says the insurance company's in-network rate under Plan A negotiated got a 77% discount!!! This isn't unusual. I've had the misfortune to see some hospital charges discount by 90%. Look at the reports about hospital "chargemaster" billing. The numbers are set high on the assumption that there'll be a massive discount.

Unfortunately, your insurer has already paid 19.8K (60%) and now is coming after you for the other 40%. You'd really rather that insurance not cut that check just yet. The bill should be around 7.5K. Be happy if it's around 10K, so that your 40% share is $4K. But the hospital would be ecstatic to get 19.8K + more money from you. You'd be among that rare slice that ponys up the sticker price. And you don't want to be that person.

So you need to negotiate the bill down, and only then split it w/ your insurance. And I _think_ that they can't cut you a discount on your 40% share w/o also giving the insurance company the same discount on their 60% share. Now, if the hospital cashes a check for $19.8K, they're not going to be terribly motivated to discount things. You need to get this $33K bill discounted down to 10K.

Ain't this a really messed-up system? Good luck...

PS, I agree w/ the others. The dr's office isn't technically at fault. Theoretically, you're "supposed" to handle things w/ insurance, but they do it as a service. The insurance companies are hard to work with and it's not like it's in their interests to pay out. That said, ask nicely, and see if they can help you negotiate a fair bill
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Re: Hospital/medical bill - need advice

Post by random_walker_77 »

Can't vouch for the site, but this page looks like reasonable advice, especially the part about getting negotiated bill settlements in writing:
https://www.healthcarebluebook.com/page ... x#section6

another relevant article: http://www.forbes.com/sites/nextavenue/ ... -now-what/
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Re: Hospital/medical bill - need advice

Post by goodenyou »

And I get asked WHY I don't recommend going to medical school? :oops:
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gasdoc
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Re: Hospital/medical bill - need advice

Post by gasdoc »

random_walker_77 wrote:
squirm wrote:
This is off the main topic, I currently have a claim with my insurance to reimburse me for the surgeon fee's since I paid out of pocket for his services. I paid $3100. The insurance in theory is suppose to reimburse me 50% of the "allowed amount" which will probably be 50% of $1800. My surgeon said he doesn't take my insurance because the reimbursement rate is so low...However this is a separate item from the real issue which is the provider fee's.
Again, there's the sticker price and then there's the price that is typically paid (b/c of negotiated discounts). Your bill is for $3100. In-network, your insurance would get a big discount. They consider $1800 to be typical, and so they'll pay 50% of that. Your job is to negotiate the main bill down under $2000. (or come up w/ evidence that $1800 is unrealistically low for that procedure in your area).
squirm wrote: Back to the main topic. So you're saying that the 40% of my co-insurance (Plan B that has no cap) actually could count as me not being insured and I could make a claim to get reimbursed from that. I will look into that. That sounds similar to what I'm currently doing with my surgeon fees as described above.
I'm suggesting that you're getting a 0% discount. Your objective is to negotiate a discount away from the unrealistic sticker price. Then you split the bill w/ insurance 40/60 as per your policy.
squirm wrote: When I spoke to my insurance they told me that the provider submitted the bill to them. The provider (the hospital) submitted roughly a $33,000 bill. Per my Plan B, the insurance paid 60% of that. The provider therefore charged me with the remaining 40% or about $15,000. If I understand this correctly, I can negotiate the $15,000 bill with the hospital and (hopefully get it reduced) and the remaining amount that I pay to the hospital I can submit to the insurance in hopes of getting a reimbursement?

I also did want to throw this out there again, what role does my surgeons office have in this? They scheduled the surgery and date. They told me the provider was a In Network provider with the insurance I had. I have an apt with the admin person tomorrow to discuss this and would like to prepare some pertinent questions. I really like my surgeon and his staff, they've been remarkable for my care so I will keep very civil.
You know that this $33K bill would've been paid out at $7.5K, whereupon your 40% would come out to $3K. That says the insurance company's in-network rate under Plan A negotiated got a 77% discount!!! This isn't unusual. I've had the misfortune to see some hospital charges discount by 90%. Look at the reports about hospital "chargemaster" billing. The numbers are set high on the assumption that there'll be a massive discount.

Unfortunately, your insurer has already paid 19.8K (60%) and now is coming after you for the other 40%. You'd really rather that insurance not cut that check just yet. The bill should be around 7.5K. Be happy if it's around 10K, so that your 40% share is $4K. But the hospital would be ecstatic to get 19.8K + more money from you. You'd be among that rare slice that ponys up the sticker price. And you don't want to be that person.

So you need to negotiate the bill down, and only then split it w/ your insurance. And I _think_ that they can't cut you a discount on your 40% share w/o also giving the insurance company the same discount on their 60% share. Now, if the hospital cashes a check for $19.8K, they're not going to be terribly motivated to discount things. You need to get this $33K bill discounted down to 10K.

Ain't this a really messed-up system? Good luck...

PS, I agree w/ the others. The dr's office isn't technically at fault. Theoretically, you're "supposed" to handle things w/ insurance, but they do it as a service. The insurance companies are hard to work with and it's not like it's in their interests to pay out. That said, ask nicely, and see if they can help you negotiate a fair bill
No offense to the above poster, but in my experience the amount the insurance company actually paid to the hospital or other providers has had little to do with the ability of the patient to negotiate with the provider. Just negotiate nicely with the hospital and you should be fine. It is not at all unusual for the provider to get the insurance payment based on one billed total amount, and then the provider discounts down the patient portion due to hardship or whatever. Theoretically, the provider has to give the insurer the same discount it gives the patient but in my experience, this is not done routinely, so there is no reason to involve the insurance company in the negotiations at all, as long as the provider has a good reason to discount the patient, and it is not done as a matter of course (somewhat off the record). Again, just negotiate nicely with the hospital- it is not as complicated as the previous poster is making it out to be.
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squirm
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Re: Hospital/medical bill - need advice

Post by squirm »

Everyone,
Thank you so much for your detailed responses and advice. It is much appreciated. I feel I have gotten good advice and will now disengage from this thread. I will update it as this saga moves forward if I have other pertinent questions, otherwise I will let everyone know how it ends.

Thanks again!
toofache32
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Re: Hospital/medical bill - need advice

Post by toofache32 »

I came across 2 articles that have good insight into the confusion highlighted by this thread, especially what the patient is responsible for and what the doctor's office is responsible for. I think it requires registration but it's free:

http://www.physicianspractice.com/medic ... onsibility

http://www.physicianspractice.com/medic ... onsibility
elchris
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Re: Hospital/medical bill - need advice

Post by elchris »

Squirm good luck, I know this must be a very stressful situation to be faced with such a large bill.

What a mess the healthcare system is! The lines of responsibility are very blurred, the patients are always misinformed about the process, insurance companies could not make the process more confusing if they tried, and hospitals don't help with employees who have no idea what they are doing with the hundreds of billing codes.

I really liked this, it may be the only way to navigate such a complex system and just maybe, once non-healthcare providers need to understand the insurance (foreign) lingo, it may all become more simplified!!
SHARED RESPONSIBILITY
• Both parties will conduct a benefits check. While the patient will probably argue with this statement, they are ultimately responsible for knowing what their plan is and what it will cover. However, for the sake of getting paid, I'm putting this under the "shared" list. It's very important for both parties to make sure the insurance representative told the patient and the provider the same benefits. I've found as high as 40 percent of payers provide incorrect benefits to physician practices. Had the patient called the payer, as well, to confirm her benefits, that conversation could happen at the time the benefits are being explained — saving a lot of frustration and headache later.
Question for everybody else who may know:
1) To avoid such situations in the future could the patient ask the doctor's office to get a pre-determination in advance IN WRITING from the insurance company before any procedures are performed? Would this include/cover other professionals eg. anesthesia who may be our of network?
2) For the patient to get a pre-determination/quote from the insurance company, how can one ensure they are given the correct codes from the hospital/physician's office?
toofache32
Posts: 2349
Joined: Sun Mar 04, 2012 5:30 pm

Re: Hospital/medical bill - need advice

Post by toofache32 »

elchris wrote:Squirm good luck, I know this must be a very stressful situation to be faced with such a large bill.

What a mess the healthcare system is! The lines of responsibility are very blurred, the patients are always misinformed about the process, insurance companies could not make the process more confusing if they tried, and hospitals don't help with employees who have no idea what they are doing with the hundreds of billing codes.

I really liked this, it may be the only way to navigate such a complex system and just maybe, once non-healthcare providers need to understand the insurance (foreign) lingo, it may all become more simplified!!
SHARED RESPONSIBILITY
• Both parties will conduct a benefits check. While the patient will probably argue with this statement, they are ultimately responsible for knowing what their plan is and what it will cover. However, for the sake of getting paid, I'm putting this under the "shared" list. It's very important for both parties to make sure the insurance representative told the patient and the provider the same benefits. I've found as high as 40 percent of payers provide incorrect benefits to physician practices. Had the patient called the payer, as well, to confirm her benefits, that conversation could happen at the time the benefits are being explained — saving a lot of frustration and headache later.
Question for everybody else who may know:
1) To avoid such situations in the future could the patient ask the doctor's office to get a pre-determination in advance IN WRITING from the insurance company before any procedures are performed? Would this include/cover other professionals eg. anesthesia who may be our of network?
2) For the patient to get a pre-determination/quote from the insurance company, how can one ensure they are given the correct codes from the hospital/physician's office?
Please don't take offense, but have you ever seen a pre-determination? I mean have you ever read the actual piece of paper? At the bottom in small letters it always says, "pre-determination of benefits is not a guarantee of payment." In other words, it means nothing. Most people would be amazed at how often insurance companies change their minds after services have already been provided. For this reason, my office no longer bothers.....either way, if the insurance company doesn't pay then it's the patient's responsibility.
elchris
Posts: 36
Joined: Tue Dec 16, 2014 6:18 pm

Re: Hospital/medical bill - need advice

Post by elchris »

toofache32 wrote: Please don't take offense, but have you ever seen a pre-determination? I mean have you ever read the actual piece of paper? At the bottom in small letters it always says, "pre-determination of benefits is not a guarantee of payment." In other words, it means nothing. Most people would be amazed at how often insurance companies change their minds after services have already been provided. For this reason, my office no longer bothers.....either way, if the insurance company doesn't pay then it's the patient's responsibility.
No I have never needed one but at the same time, then what's the "due diligence" on the part of the patient? The insurance company can't just up and "change their mind" without any legal obligation? What is the patient to do then? If you call it's all verbal and probably even worse than a pre-determination, if they are able to renege a written document. (I know you are going to say I am being too naive ... in a perfect world etc ... and though I despise their methods, I am trying to figure out what's the best way this doesn't happen.)
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