What are "Adjustments" to my medical bill?

[robby]

@echoreply

@suranyi

the contract between the hospital and the insurance company prohibits the hospital from billing the patient for this difference

Yes, it’s called “balance billing” and is prohibited in some circumstance, but allowed in others.

It is generally allowed if you seek non-emergency care at an out of network facility. Your insurance may cover some of that cost, and you will be responsible for the rest.

If you go to an in-network facility, but receive out-of-network care; or in the event of an emergency, you cannot be billed for the balance. Your insurance will pay the contracted rate (at an in-network place) or a “reasonable and customary” rate at an out-of-network emergency room, and you cannot be billed for the difference.

One of the exceptions in which balance-billing is still allowed for emergency care is [ground] ambulance services (as opposed to air ambulance services like LifeStar helicopters).

The reason for this carve-out is reportedly because many municipalities own their own ambulance services and they all whined they would have to raise taxes otherwise. Of course the privately-owned ambulances benefit as well. Lawmakers eventually decided to fight that battle another day, so ambulance services, which apparently are out-of-network for virtually all insurance companies, can balance bill to their heart’s content.

And what’s even more aggravating is that many municipalities have contracted out their billing and collection services to private companies like COMSTAR, who aggressively market their services to the municipally-owned ambulance services. So the first bill you get is from COMSTAR, and if you don’t pay the full amount beyond what your insurance pays, they are the collection agency as well and will promptly initiate collection efforts.

I ran into this shitshow last year when I took the first ambulance ride of my life after a serious skiing injury. Because I got three medications by IV (two doses of pain medication and an anti-nausea medication), my trip was billed as the highest level of care, Advanced Life Support (ALS) Level 2. I got a bill for $3,500 for a 20-minute ambulance ride, of which my very good (Blue Cross Blue Shield) insurance paid the maximum in-network rate of just about half that amount.

However, the ambulance service is out-of-network (as is typical for ambulance services), so COMSTAR then proceeded to hound me for the difference. They absolutely refused to negotiate or give me any discounts. After 9 months of trying to get my insurance company to pay more, or for them to accept a lower amount, the best I could get out of them was a monthly payment plan for the remaining $1,700. I’m still paying this off.

As I said to my insurance company and the ambulance service, “Was I supposed to look for an in-network ambulance? I didn’t even call for the ambulance in the first place!”

It’s quite a rigged system, and I wish it would be addressed by lawmakers.