I wish for socialized medicine.
September 14, 2012 2:14 PM   Subscribe

I went to the ER. The doctor claims to not honor my insurance's discount. My insurance claims the doctor is in network and should honor it. I did not pay the difference and it has now gone to collections. The collections agency said I signed an agreement to pay all fees, so I'm on the hook for this amount. (But I obviously disagree.) How should I proceed?

Adding to that, my insurance has an annual deductible (which I've passed). So I don't feel like I should pay for that amount myself out of pocket either way. I tried calling the collections agency, but the woman was very b**chy and not at all helpful about how I should proceed to dispute it.

Should I try to get confirmations in writing of whether the doctor is in network or not? (And how would I go about that?) Should I go to small claims? Who should I sue, the doctor (billing agency) or the collections company?

Or should I just suck it up and pay the collections agency? In that case, how can I pay as little as possible and still try to preserve my credit?
posted by ethidda to Work & Money (10 answers total) 3 users marked this as a favorite
Best answer: Is the insurance provided by your employer? If so, the HR / benefits office might be able to help you navigate this.
posted by jon1270 at 2:33 PM on September 14, 2012

You haven't mentioned the jurisdiction or the insurer, but you shouldn't, because you need to go straight to a lawyer - after getting advice from your employer's benefits manager if your insurance is through your employer.
posted by Blasdelb at 2:35 PM on September 14, 2012 [2 favorites]

Some doctors have two businesses with two tax numbers. One is in network and one is not. If you check ny name it looks like they're in network but if they bill you from their "other business". You're SOL. Total dick move but pretty common. Check the tax ID or Duns or license numbers of the business that charged you vs the one covered in network

Fwiw, I told my doctor I'd take him to small claims and he rebilled me under the in network account but it didn't go to collections. This was on the advice of his office staff who clearly disliked him.
posted by fshgrl at 2:38 PM on September 14, 2012 [1 favorite]

Doctor's practices usually bill separately from the hospital or facility charge. That's why you can get a separate bill from the radiologist for reading the x-rays you had done at the hospital, a separate bill from the pathologist for examining the tissue you had removed at the hospital. At my local hospital, the hospital itself has a contract with my insurance provider, but the ER physician's practice (which bills separately for the professional charge) does not have a contract so they are considered out of network, although the hospital is in network. Could that be what is going on with your charges?
posted by SweetTeaAndABiscuit at 3:03 PM on September 14, 2012

You probably don't need to sue anyone - you're not trying to get money out of people, you're just trying to make sure they don't take more from you than you really owe. You should gather all the relevant information first.

The easiest way to get all the billing paperwork is to dispute the debt - the collections agency will have to gather everything - the bills, the breakdown of what portion was paid, and when, and by whom, as well as any paperwork you signed supposedly taking responsibility for the debt. They will have to provide all this to you to try to prove you owe it.

You should have also received from your insurance company, an Explanation of Benefits that shows exactly what they did and did not cover for this visit. It will break down the original billed amount and payments toward it: the amount you paid via co-pay; the amount they paid, per their agreement with the doctor and/or hospital; and the amount discounted from the original fee, which simply accounts for the difference between the original bill and what was actually paid. This should all balance to zero in the last column.

The difference between these two documents should show where the conflict appears.
Remember - if the doctor really is in-network, the agreement he signed with your insurance company prevents him from collecting anything other than a co-pay from you as long as the visit was covered by your insurance - which it sounds like it was.

So...first step - tell the collections agency that you dispute the debt. Tell them they must provide proof of the debt. This means the burden is now on them to prove you owe it, rather than on you to prove you don't. While you're at it, tell them to cease calling you and that all further communication must be in writing. That should help save your sanity a bit in the meantime.

They may just drop it completely. But probably not. So once they send you the documentation noted above, take a good hard look at the paperwork you signed. Usually it says you agree to pay all charges only if your visit isn't covered by insurance. Since your visit presumably was, you should then be in the clear. Write a concise letter to the agency (CC: the doctor's billing office) laying out these facts.

If they continue to pursue the debt further, that's when you call in the lawyer. Doing all this work yourself up front will save you lots of money from a lawyer's hourly fees to do the exact same things.
posted by trivia genius at 3:04 PM on September 14, 2012 [4 favorites]

Also - if it turns out that the doctor is out-of-network but your insurance indicated that he is - you need to appeal to your insurance company to cover the difference because it was their mistake and not yours.
posted by trivia genius at 3:06 PM on September 14, 2012

If you're in the US, you need to contact your state's Insurance Commissioner pronto. I was in exactly this position a few years ago and the insurance company suddenly decided to do the right thing.
posted by workerant at 3:23 PM on September 14, 2012 [2 favorites]

In the future, with billing disputes, it's a good idea to deal with the problem before it goes to collections...

I had a similar problem a couple of years ago. There, much of the ER visit was covered, but the doctor who happened to be on call with the hospital, although he was in-network as part of his practice in another city, was in Fairbanks working as a Locum (temporary) doctor and was not in network in Fairbanks. Even though he was on salary with the hospital.

What eventually worked for me after I received a $6000 bill from the hospital that insurance said I owed was to (1) Call the hospital billing number and have a lot of conversations to figure out what the exact issue was; (2) appeal the charge with the insurance company, which was denied; (3) report to the hospital that the appeal was denied; (4) the hospital agreed to waive the charges (after I signed some papers).

But it doesn't really sound like you've had conversations with the billing company or your insurance company; you don't get to just decide to not pay a bill! Collections can't do anything for you at this point---and I don't know what the doctor's office/insurance company can do once it's been sent to collections.

My parents claimed that they paid off a very large hospital bill in $5/month increments for 20 years; lots of times if hospitals are being paid something, they will stay off your back. But you need to have conversations with them.
posted by leahwrenn at 3:30 PM on September 14, 2012 [1 favorite]

What trivia advises will not work if you don't have some way of identifying the doctor beyond name. Or business name. The exact same person can have 2 businesses or more, and only one in network then they will you as the other. This did NOT show up on any of the paperwork and I have had to get tax ids twice to sort this out.
posted by fshgrl at 5:47 PM on September 14, 2012

Response by poster: So my first step was contacting the benefits people, who talked with the insurance, who talked with the hospital and now the discounts are being applied. I'm glad it was much easier than I expected, but also scratching my head at why this step was necessary.

Thanks for all the advice!
posted by ethidda at 1:06 PM on November 12, 2012

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