More insurance questions

[jessmarimba]

So...I'm sure almost everyone on this forum has had to deal with hospitals at some point, no?

Is there any chance of settling a bill for out-of-network physicians at an in-network hospital? Apparently I owe about $900 for physicians that I NEVER SAW who stopped by and read my chart, or something. The insurance website claims that they paid nothing, but that my member cost should only be about $300...but whatever billing center these guys used wants all of the money.

It's not like I was even given a choice of checking their network status. I didn't even know these guys existed until the bill came today (they aren't affiliated with the surgeon, anesthesiologist, or any of the imaging services). So frustrating.

Do I appeal to the insurance? The center the physicians bill through? The hospital?

[BikeDutchess]

It's not uncommon for "hospitalists" to provide care when you are inpatient. Like other hospital-based physicians, they may or may not have a contract with your insurance company. If not, the insurance may only allow a "reasonable and customary" amount, which in turn could be applied to your deductible (I suspect that's what the $300 represents). The physician will then balance bill you for the difference between the R&C amount and the total billed charges, in addition to the deductible you're already responsible for.

I would advise you to contact your insurance company - start by calling the customer service phone number. Some companies even have a "Live Chat" feature on their member website (I love this because you can print a transcript of the chat). Many companies have a policy that they will reprocess the claim to allow full billed charges if the patient is being balance-billed by a hospital-based provider. Of course you may still be on the hook for the amount if you haven't met your deductible yet.

[JennK13]

"Apparently I owe about $900 for physicians that I NEVER SAW who stopped by and read my chart, or something. The insurance website claims that they paid nothing, but that my member cost should only be about $300...but whatever billing center these guys used wants all of the money."

You may be able to argue some of those charges as well, just like any other bill you receive. Perhaps I'm a skeptic, but I've heard of a lot of people being billed for bogus charges at hospitals. Sounds like you have no idea who these physicians are or what they did. At the very least, I'd find out what the heck you're paying for, and what service they provided to you. How many doctors are listed? What did they all do? If it was just consults on your chart, why were so many people needed (worries me about what the attending physician does or doesn't know!). Although never this extensive, I've contested items such as lab fees, and "extra" charges for procedures that I did indeed get reversed. There are those out there who try to take advantage of the fact that not everyone reads their bill, and those of us that do probably don't understand a lot of it.

[OakLeaf]

The NYT has a timely article today: http://www.nytimes.com/2010/09/14/he...tml?ref=health

[jessmarimba]

Whew. Well, the insurance and the physician's network are reviewing the costs. The insurance says the physicians were out-of-network, but will be re-reviewed for an in-network rate because it was emergency care. The physician's network says that they are in-network. Either way...my fingers are crossed.

I think the physicians were people who were consulted prior to surgery (to decide to call in my surgeon) and after surgery (since my surgeon only works on emergency trauma cases and isn't regularly at the hospital). Just a guess though.

And wow - thanks for the article - my "itemized" bill from the hospital has a "pharmacy/supplies" (yes, that's as itemized as it got) cost of over $72,000 (!!!!). I guess the insurance wasn't too particular and just paid all of that, but it is really and truly insane. I should've gotten to keep the hospital bed for that price

[emily_in_nc]

And wow - thanks for the article - my "itemized" bill from the hospital has a "pharmacy/supplies" (yes, that's as itemized as it got) cost of over $72,000 (!!!!). I guess the insurance wasn't too particular and just paid all of that, but it is really and truly insane. I should've gotten to keep the hospital bed for that price

Wow, I'll say ! I missed what you were in for, but my entire bill from Duke for ER care, x-rays, CT scan, meds (lots), major orthopedic surgery, 5-day hospital stay, PT, and medical equipment rental (hospital bed in my home) when I had my cycling accident in 2005 was "only" about $45K as I recall. Insurance covered 90%, I paid 10% out of pocket (but later got it reimbursed by the insurance of the folks whose dogs caused me to have the accident). This was all in-network care. Amazing what a racket it all is!

[ny biker]

Whew. Well, the insurance and the physician's network are reviewing the costs. The insurance says the physicians were out-of-network, but will be re-reviewed for an in-network rate because it was emergency care. The physician's network says that they are in-network. Either way...my fingers are crossed.

I think the physicians were people who were consulted prior to surgery (to decide to call in my surgeon) and after surgery (since my surgeon only works on emergency trauma cases and isn't regularly at the hospital). Just a guess though.

And wow - thanks for the article - my "itemized" bill from the hospital has a "pharmacy/supplies" (yes, that's as itemized as it got) cost of over $72,000 (!!!!). I guess the insurance wasn't too particular and just paid all of that, but it is really and truly insane. I should've gotten to keep the hospital bed for that price

I've had several experiences with insurance companies where they initially didn't want to pay for service but after I contacted them they revised things and increased what they paid. In 1993 after I had ankle surgery, I had to send them a copy of the surgeon's operative report, and then they covered everything at 100%.

More recently with the dentist, I had a filling that needed to be replaced and due to the size of the filling and the fact that the tooth was a molar that did lots of heavy-duty chewing, the dentist replaced it with an implant instead of a regular filling. At first the insurance company refused to pay for the implant, so I called them and said I wanted to appeal. I explained the reason for the implant over the phone and based only on what I said, they reconsidered and paid for the implant. I later learned that the dentist's office had included documentation with all the same information when they initially filed the claim on my behalf. I think the insurance companies figure they should deny things at first and see if anyone will make the effort to appeal.

So, hopefully you will have the same experience and they will cover those doctors' costs now that you've contacted them.

BTW, I was still getting bills for that ankle surgery more than a year afterwards. The major bills came pretty quickly, but bills for little things like the crutches I got from the hospital trickled in very slowly. Also I was frustrated by multiple bills for things like radiology and testing -- first I'd get the bill for the x-ray or MRI or lab, then a couple of weeks later I'd get a separate bill for the person who read the results. I hope things are more streamlined for you. Most importantly, I hope you heal well!