A friend of mine was sent by his doctor to the hospital, via the emergency room, without waiting to get it OK’d the insurance company. The doc believed this was fully justified. He spent two nights in observation, and it turned out OK. The hospital billed him about $10,000, of which $2200 is being billed to him.
He feels the amount being billed for just the room is excessive (I think he said it was $6000 or $7000) and doesn’t want to pay.
He talked to the hospital, but they have given it to a collection agency.
What is his best strategy here?
I have searched the Dope and found this useful thread and some others, but nothing that matches this issue exactly.
There are so many differnet kinds of health insurance out there, (PPO, HMO, etc.) that your friend first needs to scour through all the rules of their own insurance to see what they had to do in this scenario. Typically, you need to report out-of-plan hospitalization within a rather short time - IIRC, for my plan, it’s 24 or 48 hours - for it to be covered.
Doctors do thousands ot things each day that they believe to be medically justified. Unfortunately, the insurance companies do their best to pay for none of them.
Looks like your friend has an “old-style” 20-80 policy - they pay 20% and the insurance picks up the other 80%. $10,000 for an ER visit and 2-night stay is rather on the low side, I believe.
FWIW “old-style” is generally good if you don’t mind the co-pays. This could be a co-pay. I just kicked my “old-style” coverage to the curb during open enrollment, because it occurred to me that even with insurance, I was paying 100% of my medical bills, because I’d never gotten past the co-pays!
You can always dispute the bill with the credit companies but I doubt that will do you much good. I’d try working with the hospital if you can, the collection agencies just don’t care and don’t want to hear it.
I deal with this scenario at work at times - what your friend needs to do is have the doctor that sent him to the ER dictate a letter specifically stating why the pt was sent over without waiting for authorization ( why it was an emergency) , and have him appeal the claims to the insurance company. The dispute is with the insurance company, not the hospital, assuming that the insurance didn’t pay the full benefit because there was no prior authorization. If the insurance paid the correct amount per your friend’s policy, and the problem is the amounts charged, that’s a differnt story. He needs an itemized bill to make sure he wasn’t charged for services he didn’t receive, or billed double for services.
Do you mean deductibles? Deductibles are the amount you have to cover before the coverage will kick in. Co-pays are usually set amounts that you pay for at each visit/incident, regardless of whether your deductible has been met.
First your friend should work with the insurance company to see if everything was billed correctly or can be corrected.
Second, your friend should set up a payment plan with the hospital for any stuff that wasn’t or isn’t covered by the insurance company. Technically, the hospital accepting payment from insurance is a courtesy- a badly needed one in most cases.
If the hospital has given the debt over to a collection agency, your friend will not be able to pay the hospital as they no longer own the debt.
If the bill has gone to the collection agency, your friend’s best bet is to not pay until the collcetion agency calls offering a deal. It’s not uncommon for collection agencies to lob of 30% to 50% of a bill in exchange for fast payment.
Without much more information, it’s really hard to say.
The numbers aren’t horribly inconsistent with an ER visit and a two-day stay. I assume he had additional procedures done during his stay, and probably had some meds, at least one consultation by another doctor, and what-all. Again, without knowing all the details, it’s hard to make a good judgment.
If your friend is so inclined, he may appeal the insurance company’s decision on the basis of medical necessity. His doctor will have to advocate for him in explaining (and documenting) why the stay was necessary, and why whatever procedures were done couldn’t be done in an outpatient setting.
However, and this is a HUGE however, the account has been sent to collections. Hospitals typically don’t do this for recent accounts, so most likely, it’s been sitting there for a while. It’ll take some fast talking to convince the hospital to take the account back pending further insurance review, particularly since some insurance companies have such a small window for the appeals process to begin with.
All in all, I’d tell your friend to work it out with the collection agency. He owes the debt, and unless he wants this blot on his credit report, he can’t afford to stand on principle.
OK, I’ll get more information from him, as per the suggestions, and we’ll check the billing.
If all else fails, he can try the immediate-settlement-for-half-cash offer.
The letter the agency sent said it was the final notice, but it didn’t say final before what? --lien on home? send out Vinnie the leg-breaker? write it off (ha)?
The bill was over $10,000. The $2200 being charged to my friend was the deductible.
The hospital charges $3240 per day for the room (!), but it is a contract hospital with the insurance co, I think BlueCross, which pays $1725 per day. It looks as if the hospital accepts that in full for the room charge. Then there were the tests, etc.
It turns out that the matter has not actually gone to collections. The letter came from the hospital’s internal people.
My friend may try for a deal as suggested, with a big discount for immediate payment. And he might go over the itemization, although a year is a long time to keep track. The information you guys have provided is much appreciated. If there is anything else to add, please don’t hesitate!
PS, what happens if you have, say, a house and no insurance? Do you end up paying $3240 per overnight plus all the tests and procedures?
If you have no insurance, you may as well sell the house because you will be expected to pay the full amount. Providers accept insurance for a couple of reasons. First, 10 patients at 50 bucks a head is better than 1 patient at 250 bucks. Second, insurance companies pay off reasonably quickly. A self-paying patient may not. Basically, uninsured patients who pay their bills subsidize everyone else. Yes, it’s a problem, but until universal health insurance is a reality, it’ll still be a problem.
If the $2200 is being called a “deductible”, he’s obligated to pay it. Going over an itemized bill is a colossal waste of time, because the insurance paid its portion. Deductibles are part of his contract with Blue Cross, and it’s usually something that is emphasized in their literature. His best bet is to settle with the hospital for whatever terms they’re offering.
Really, if $2200 is the deductible, and he can find that in writing in his policy, then that’s it. The best he can figure on is time payments, or bankruptcy if this is kind of a last-straw expense.
If he disagrees what the deductible is, he can ask the insurer to provide documentation as to where that number came from. Once he receives it and continues to disagree, or if they fail to provide it, the next step would be an appeals process.
To be honest, I don’t think there’s much your friend can do. $2200 for a two-night stay in an American hospital is extremely reasonable. My insurance policy has a $2500 deductible, with the insurance company covering 100% over that amount. I assume that ANY trip to the ER or stay at the hospital will cost me the deductible of $2500.
I mean, seriously, what’s the best your friend can hope for? His deductible was $2200. Even if the hospital overbilled him by $5000, he’d still be responsible for the deductible.
And if it is the deductible, then let your friend know that next time he needs medical treatment during his plan year, the deductible will be so much less. For example, if his deductible is $2500 per plan year, he’s only got to pay $300 more out of pocket until the insurance picks up everything else (plus co-pay, if any. Some plans have maximum out of pocket expenses equal to the deductible).