Help me figure out a Kafkaesque hospital billing problem. I am in an HMO and live in California. (Surprisingly, the problem does not seem to be with the HMO itself.)
(Anonymous because my mefi account is connected to my name and I don’t trust collection agencies; I’m happy to follow up via one of the mods, though, if need be. Also, sorry for length.)
In May of last year, I was admitted overnight to Cedars-Sinai in Los Angeles after being sent to the ER from an Urgent Care visit. According to my coverage, my only responsibility would be my $250 hospital copay.
A few months later, I began receiving the paperwork from the hospital (i.e., statements showing what claims were pending with the HMO) and paperwork from the HMO (i.e., Explanation of Benefits [EOBs] that showed what they were covering on those claims). Eventually I received the bill for my $250 copay from Cedars, which I immediately paid in full.
However, I also started receiving—from Cedars, not from my HMO—multiple bills for the doctors who saw me in the hospital after I’d been admitted (i.e., not in the ER but up in my room). According to my HMO schedule of benefits, such in-hospital consultations are covered at 100%, with no patient copay.
Thus begins the Kafkaesque runaround. Over the course of several months, I repeatedly called Cedars-Sinai billing services, who would say that these claims had been rejected by my HMO and were therefore my responsibility. However, whenever I would call my HMO, they would say that they never received these particular claims in the first place (unlike all the other claims related to my ER/hospital stay, which were in their system and had been processed).
Then I would call back Cedars and say that the HMO had never received the claims; Cedars would say that they needed the HMO to send them the EOB proving that they never received the claim; I pointed out that the HMO couldn’t generate EOBs for claims they never received in the first place. (This would usually be followed by silence, then the second verse—same as the first!—would begin again.)
Everyone I have spoken with at my HMO consistently confirmed that I am not responsible for the fees associated with these in-hospital consultations, and that they would be happy to process the claims—just like every other claim—if only Cedars would submit them.
Over the fall, my HMO contacted Cedars directly, requesting the claims and also sending a copy of my schedule of benefits showing that I do not have an in-hospital copay for doctors’ consultations. Still no dice. Finally, in a conference call between me, my HMO, and Cedars, in late November, Cedars agreed to submit the claims to my HMO.
You can see where this is going. When I followed up the next month, Cedars said they’d done it. My HMO said they’d never received the claims. The punch line arrived yesterday, when I received a notice from a collection agency for these bills (though strangely, for a slightly lower amount than what Cedars has been claiming all along). I followed up with my HMO and they confirmed that, indeed, none of those claims were ever received.
Okay, so obviously I will dispute the claim in writing with the collection agency. Thus Question 1
: what’s the best way to word this? Is a generic dispute letter
good enough, or is there other wording I should include that would be more appropriate for these circumstances?
: Is there anything that can be done to get Cedars to, you know, just submit the claims already? (Or is this totally off the table now that they’ve been sent to collection?) I have left a message with their “Department of Quality Improvement” (snort), which seems to be the closest thing they have to an ombudsman.
: Any other options I’m missing? I called the California Dept. of Managed Health Care (via the California Office of the Patient Advocate) and the guy I spoke with said there’s not much they can do; they are equipped to handle grievances against insurers, but not hospitals. (His only suggestion was, “well, you could always file a grievance against your HMO, even though they’re not the problem, and see if that helps. If it doesn’t, we might be able to get involved after that.” Is this good advice or not?)
Thanks in advance.