How to get a hospital to properly submit claims to an HMO instead of incorrectly billing me?

February 2, 2010 7:06 PM

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?

Question 2: 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.

Question 3: 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.

posted by anonymous to Work & Money (9 answers total)

Physicians in California are not employed by hospitals. The work they do in hospitals is done as an independent contractor; the contract is between you and the physician, and is pretty well implicit in your not refusing care.

You probably confused whomever you spoke to at Cedars, or else you yourself were confused, when you gave yourself to understand that the hospital had anything to do with bills you received from physicians.

What you should have done was to call the offices of the individual doctors who billed you, or their billing service or agency. That contact information should be present on the bill. Those doctors, and their billing service, might not know that you are in your HMO; or they may not be contractors with your HMO, meaning that you were out of network when you were treated by them. You might still try this, but these offices have already written you off as a loss when you were turned over to collections, so they may have limited ability to intervene at this point.
posted by Protocols of the Elders of Sockpuppetry at 7:24 PM on February 2, 2010

It sounds to me like you are in a he said-she said: Cedars says they submitted claims, the HMO says they didn't. I get your point that the HMO can't really prove non-receipt, so why don't you ask Cedars to prove filing? Ask them to send you a copy of their claims submission. If they won't provide that, obtain the claim number and date of submission. I suggest this because I am stuck in the middle of a battle between a medical provider who swears she submitted a claim form (on a visit for which she insisted I pay, and then be reimbursed) and my PPO says she never submitted it. I find the PPO more credible on the issue than the doctor, since she the doc can't produce a copy of the filed claim.

It's not necessarily a solution, but I think it does help you get needed info. I don't see anything that makes me believe the HMO over Cedars as to the status of submission. I would make all requests in writing and get all collection activities in writing, but that is not legal advice - just my own practical preference to deal with scumbags like this through written correspondence only.
posted by bunnycup at 7:27 PM on February 2, 2010

Physicians in California are not employed by hospitals. The work they do in hospitals is done as an independent contractor; the contract is between you and the physician, and is pretty well implicit in your not refusing care.

Really? None of them are employed by hospitals?

As a member of a medical family, I find that impossible to believe. Sure, many doctors work in private practice attached to the hospital. But there are also lots of hospitalists who are employed directly by the hospital and receive a salary.

Perhaps this all-doctors-are-in-private-practice thing is peculiar to California... but, I kinda doubt it.

And if it's the hospital doing the billing, sending out the harassment letters, and finally shipping it to a collection agency... well, it doesn't sound like the individual doctors anyway.
posted by Netzapper at 8:12 PM on February 2, 2010

Forgive the obvious question, but is there a reason why you simply didn't...forward the paperwork the hospital sent you TO the insurance company from the get-go?

I was in a similar situation -- hospital sent me bill, said "your insurance didn't pay it," and insurance said "we never got the claim" -- but when I sent my insurance company the bill that the hospital sent me, my insurance company said, "okay, thank you, now we can work with this," and...that was all it took.

I don't think the HMO really CARES who sends them the paperwork, as long as SOMEONE does. So I'm just wondering why YOU didn't do that, since it was right there in your hand.
posted by EmpressCallipygos at 8:21 PM on February 2, 2010

From the original poster:

Re: Protocols of the Elders of Sockpuppetry's assertion that "physicians in California are not employed by hospitals" and that I probably saw out-of-network doctors: sorry, this is false. One of the doctors who I'm being billed for is Cedars' own lead hospitalist of inpatient specialty programs; by definition, he's employed by the hospital.

All the other doctors I saw during my stay are in the hospital's primary physicians' network. While the physician billing services and the hospital billing services are indeed different sub-departments, they are both under the umbrella of the Cedars-Sinai billing office. The bills are on Cedars letterhead, with a Cedars return address (located in the actual hospital complex itself), with a Cedars phone number, answered by people who say "Cedars-Sinai billing," who have readily agreed, in conference calls with the HMO, to submit the claims. There is no independent third party involved.

Re: EmpressCallipygos's "Forgive the obvious question, but is there a reason why you simply didn't...forward the paperwork the hospital sent you TO the insurance company from the get-go?." I did send my HMO the paperwork pretty early in the process (sorry not to have made that clear). They thanked me, said that it was helpful for confirming that they never received the claims, but that they still needed the actual claims (i.e., not "the paperwork in my hand") submitted by Cedars-Sinai to proceed any further.

posted by mathowie at 12:01 AM on February 3, 2010

It sounds to me like you are in a he said-she said: Cedars says they submitted claims, the HMO says they didn't. I get your point that the HMO can't really prove non-receipt, so why don't you ask Cedars to prove filing?

I think this is the best route to pursue. I strongly suspect that Cedars has submitted the claims incorrectly in some way - there are a zillion details that could go wrong, the end result of which would be that the HMO did not match up THESE claims with YOUR record.

And if that doesn't work, you could always set the building on fire or something.
posted by shiny blue object at 2:51 AM on February 3, 2010

Ah, thanks for the clarification.

And I hope that my next question doesn't sound combative, but I'm honestly puzzled -- why didn't the insurance company contact the doctors themselves, and take you out of the middle? I've had similar cock-ups like this, but my forwarding the papers I got to the HMO always made them say, "okay, thanks -- now that WE know who to contact, you just chill and we'll take it from here." and things sorted out in short order after that.
posted by EmpressCallipygos at 4:53 AM on February 3, 2010

One more longshot tip, but something that's always good to double check... Take a look at the paperwork and make sure every piece of identification data (insurance account #, SSN, etc.) is absolutely correct. Most insurance claims systems are automated to the point that a human won't catch such errors, so that it really can appear that the claims are never received (because the claim is never matched to you, the insured.)

I went through something like this a year ago, and it turned out that one very long string was off (with a 0 instead of an O). Six months of ridiculousness evaporated in minutes.

Again, a long shot, but check every detail...
posted by j-dawg at 5:09 AM on February 3, 2010

One of the doctors who I'm being billed for is Cedars' own lead hospitalist of inpatient specialty programs; by definition, he's employed by the hospital.

No, actually. Check out the Stark Laws (and their relative, the anti-kickback statute) for some mind-numbing legal commentary on the issue, if you care. For example, you've heard of Kaiser-Permanente; Kaiser runs the hospital; it contracts with the Permanente Medical Group. Cedars runs the hospital and contracts with the Cedars hospitalist group; the compensation has to be structured a certain way in order to avoid conflict with these Byzantine laws. One of the things hospitalists can't do is be straight employees of the hospital. For this reason, a lot of hospitalist groups bill separately from their hospitals.

However, if that hospitalist group really does its billing through the Cedars billing service, then what you describe shouldn't have happened.

Have you tried speaking with the hospitalist doc who took care of you? If he's the head of that group, he may know how the billing is done and be able to find out where it screwed up. You may also ask for a paper confirmation from the billing service that the claims were submitted; you could then send this to your HMO and ask them why they don't acknowledge receipt. It could be as simple as a wrong SSN.
posted by Protocols of the Elders of Sockpuppetry at 12:23 PM on February 5, 2010