The hospital where I was born is trying to screw me.
January 9, 2012 4:42 PM   Subscribe

We live in California. My wife had to go to the ER in my Virginia hometown last year. She gave them her insurance info. Four months later, they sent an enormous bill for a small amount of care.

She called them back, and they admitted they hadn't even tried to bill our insurance because "it was commercial and from California." She asked them to bill again. They failed to follow proper procedure in their further attempts to collect from our insurance (billing our local care provider back in California instead of following the instructions on our insurance card, among other things).

Last week we got a letter from our insurance provider stating that they wouldn't pay because the ER didn't submit a claim properly in a timely fashion. Today we got another bill for the same ridiculous amount (seriously, $700 for two prescriptions filled the next day?). We're willing to pay our ER copay of $100. Does anyone have any advice on how to deal with this situation?
posted by infinitewindow to Work & Money (13 answers total) 2 users marked this as a favorite
Best answer: Appeal to the insurance company imho. This is just the sort of thing appeals were made for.
posted by thirteenkiller at 4:53 PM on January 9, 2012

I would go at it on two fronts. First, I would go through a formal appeal with the insurance company. At the same time, I wonder if there's a regulatory agency in Virginia (maybe through the Dept. of Health or the Attorney General's office) you can contact regarding the hospital's refusal to bill their services in a timely manner. Contact the agency in writing, citing the name of the person your wife talked to, and the date of the conversation (I assume she wrote it down? If not, start documenting everything), in which they said they didn't bother to follow procedure.
posted by scody at 5:05 PM on January 9, 2012 [1 favorite]

I'd send a tattle letter. Find who regulates them. Write a letter to both, with both names on the top line like so:

[Name of person at Agency]
Address, etc.

[Hospital Administrator]
Address, etc.

Dear X and Y:

Then detail everything, dates, names, places. Include documents as exhibits. CC your congressperson too.
posted by Ironmouth at 5:27 PM on January 9, 2012 [1 favorite]

Best answer: Get the information from your insurance company in writing, in which they say "Virginia ER failed to bill us in time," thus documenting the ER's error. Which you should not have to pay for. Send them a copy of the letter and if they still gripe and moan, refer them back to that letter.

I'm not sure you should even pay the copay...that is usually billed the day of service. If they didn't bill you then, and then botched everything else, there is no reason to pay them anything. But that's your call. You might ask your insurance what your copay would have been and send them that.

If they want to take it further you can talk to a lawyer, but if they were too lazy to bill your insurance, it's their problem, not yours.
posted by emjaybee at 5:29 PM on January 9, 2012

Best answer: When you go to a hospital near you, they will normally bill your insurance. It may be required, if it participates, or it may be a courtesy. When you go to a hospital on the other side of the country, it will often not submit the bill for you. It does not know the offices or the personnel. When this happens, it is up to you to get the bill to the insurance carrier for payment to be processed.

You are making the assumption that it is up to the hospital to get this done. That is not necessarily the case.
posted by yclipse at 5:32 PM on January 9, 2012 [1 favorite]

For what it is worth, many hospitals are accredited by the Joint Commission; also I had a dispute with a bank that had Virginia HQ and found that their AG's office was very quick to respond. Good luck!
posted by cestmoi15 at 5:35 PM on January 9, 2012 [2 favorites]

Best answer: When you go to a hospital on the other side of the country, it will often not submit the bill for you. It does not know the offices or the personnel. When this happens, it is up to you to get the bill to the insurance carrier for payment to be processed.

Except that his wife gave them the information; if they were not going to submit it, the time to tell her was then.

If she has copies of her admissions forms, at least one should include the phrase "I give Virginia Hospital permission to submit bills to my insurance company for my treatment," or something along those lines. It may also say she is liable if her insurance refuses to pay; however, since the refusal is not based on lack of coverage but on hospital billing error, she has a really strong case, as described, for appeal.

It really isn't that hard to contest hospital bills, especially a relatively small one like this. Make a big enough stink and it just isn't worth their while to pursue (generally) especially when they screwed up.
posted by emjaybee at 5:45 PM on January 9, 2012 [10 favorites]

Best answer: Yes, be persistent and escalate the issue. It will take a little doing on your part, but what you really want is for higher level staff on each side to be able to communicate and resolve this together.

I know it sucks, but typically the staffers hired to do billing aren't prepared or able to work outside of their norm. They need some managerial assist.

Speaking from experience, it can be done but just takes a little time.
posted by snsranch at 5:59 PM on January 9, 2012

I'm here with a different view on this than everyone else.

Yes. The hospital did not do everything it could to collect from your insurance carrier. However, the patient signs a raft of paperwork accepting responsibility for any amounts not paid by insurance. Hospitals and doctors bill insurance as a courtesy to patients. There are many doctors you can see, pay for and be reimbursed by your insurance company, because they refuse to engage in the hassle of insurance billing. Usually those providers are more up front about what is going on.

But ultimately, financial responsibility is with the patient, not the hospital, and I can assure you the insurance company does not find paying claims to be profitable. In the future this means check early and often that your claims have been submitted (your carrier can tell you), or submit them yourself of you suspect shennanigans.

Obviously, you cannot turn the clock back here, so the above is more with an eye toward next time. For now, continue to be nice, polite, and inquisitive. Do not become angry, rude or demanding. Do not tell the hospital "you will fix this" or "you are wrong." Instead, gather names, ask how they can help you, ask who within their organization you can appeal to. Same thing with the insurance company, ask them how you can get this claim paid, and who can authorize that. You are looking for the magic word "authority" not "ability." Whether a claim rep can change things in the computer is irrelevant if they will get in trouble for doing it.

Once you are confident you have spoken to, and heard no from everyone in each organization who might hold some sway (hospitals usually have an ombudsman, try them if the financial office won't solve this.), then begin cc'ing oversight bodies in your correspondence. Certified mail usually gets action if addressed to the right office. But make sure you have the right oversight body for that hospital.
Be aware that you may spend 60 plus hours on this endeavor and still have to pay the bill. I'd be very surprised if your wife didnt ink up a document promising to do just that.
posted by bilabial at 7:00 PM on January 9, 2012

Best answer: Oh. Another magic word pair is action versus attention. You don't want anybody to pay attention to this matter.

You want action, be clear about what you want in your correspondence.
posted by bilabial at 7:01 PM on January 9, 2012

Best answer: FWIW, I appealed a "timely filing" decision to Aetna by writing a letter explaining things and in words not too different from your posting. They agreed and paid the $840.
posted by bz at 11:24 PM on January 9, 2012

The California insurance commissioner might be able to help. My dental insurer was reluctant to cover a procedure. After a lot of back-and-forth with requests and denials, I finally got approval from them by threatening to contact the insurance commissioner.
posted by hoppytoad at 10:52 AM on January 10, 2012

Best answer: Mrs. Window here. Just wanted to thank everyone for the constructive answers and update. We appealed to our insurance soon after this question and just received word that they will be paying the bill, as per the terms of coverage.

So, for anyone finding themselves in a similar situation, appeal is the way to go!
posted by arishaun at 6:07 PM on February 21, 2012

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