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Yikes...medical bills and bike accident

2K views 20 replies 13 participants last post by  Lopaca 
#1 ·
A few months ago I was involved in a bike accident in CA....4 days in hospital, nothing much medically afterwards. The hospital was out of network, but this was an accident.

So the insurance pay everything they are going to pay....they did it in one of 3 ways:
1. Paid virtually everything, leaving me a small amount to cover.
2. Paid what they were going to, negotiated down the balance to something reasonable (the "adjustment") and left me a reasonable co-pay.
3. Paid some, did no negotiating apparently (there was no "adjustment") and left me with a big lump to pay.

Now, I have $1000 on the bike insurance to cover extras, but it still leaves something like 3-4000 (I haven't got it all in front of me).

Apart from the obvious "pay up", is there any way to dispute the amounts...they do seem excessive...for instance:
Ambulance, 26 miles, 1,763.00. Ins paid 1,184, leaving 578.60
Admission doc: 4 visits, $2,700, Ins paid 605.50, leaving 2,094.50
...there are several others....

Now I have written to the 5 of them and said look, the Ins company has paid up and I have paid the proper co-pay, you are simply overcharging, please adjust your charges, but that has had no effect. They have simply handed it to medical bill collectors. What avenues do I have to escape these leeches?
 
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#2 ·
First of all read your policy. Most medical providers that contract with a health provider have some agreement about the amount the insurance company will pay. Once they get that payment in most instances the obligation has been met and you are not responsible for the balance outside of your co-pay.

Send them a copy of your policy and let them know that they have accepted payment. Your policy may be different. Last case scenario have an insurance bad faith attorney review it.

These medical providers will send a billing automatically regardless of the health plan involved, but again, your policy will control.

This is just a good example of why we need as much insurance as we cab afford- liability, med pay as well as uninsured motorist coverage. Most people in California think that just because we have law requiring insurance that we don't need uninsured motorists coverage. So what do you do when you get hit by an uninsured idiot? Well, in California, uninsured motorists coverage acts as underinsured motorists coverage as well. So what if the idiot that turns right in front of us does have insurance. He may have the minimum 15,000 policy. That does not go very far with today's medical billing rates. So if you have say a 30,0000 uninsured motorist coverage it would kick in for the balance after idiot's 15,0000 policy is exhausted up to the 30,000 or whatever amount you buy.

No I am not an insurance salesman. I am an attorney and represent people who get injured by stupid people doing stupid things and believe me you can not have enough insurance. People will not even blink about spending thousands of dollars on a motorcycle but all of sudden they wallet shrinks when it comes time to buy insurance. I even purchased air ambulance insurance. They will not only cover the cost of flight evacuation (very costly) but they will fly a family member to wherever you are hospitalized if you have to be there for awhile. Very relevant for those of us that do long distance rides.

Good luck.
 
#3 ·
Thanks for the well considered reply.

1. My insurance is a few dollars under $1000/mth just for me. Hard to pay more than that! I believed I had everything I needed, some items were 90%, requiring a 10% co-pay.
2. The hospital was out-of-network, but I understood that in the case of an accident, this was immaterial and the normal payments were made. This seems to have been the case as the hospital board/lodging bill for 4 days of 24,000, they paid 23,600 of. The problem is some of the doctors, a cople in particular. The 1/2 hour admission visit was charged at 1,200 and the ins co paid 300 with no adjustments on any of that or the subsequent 3 dialy visits.

I am looking more at the doctors charging practices rather than the ins co. On my one major previous experience with the same ins co, they paid everything of a 5 day intensive care cardiac specialty hospital including angiograms, cardiograms etc etc...didn't cost a cent.

How do you tackle the automatic billing machine other than answer all their letters with a straight out "no, you are overcharging"?
 
#4 ·
I had a somewhat similar situation several years ago (not accident related though) where the insurance covered the hospital portion of the bill but only minimally covered the doctor charges. I contacted the insurance company and pointed out that they had covered the hospital portion of the bill and asked how this situation could have been handled differently in regards to the doctors bills. The hospital has a contract with the doctors and it is not like you could have shopped around for a less expensive doctor, especially when you were involved in an accident. In my case, the insurance company went ahead and covered the doctor bills to the same extent that they covered the hospital bills.
 
#5 ·
You are discovering that hospitals contract with the doctors.

If you question a doctor's a fee, the hospital passes you on.

The doctors bill by a classification, a fixed fee.

All of the hospital charges and doctor's fees charge their top rates. Insurance and HMOs negotiate lower rates.

Whatever your HMO will not pay, you get stuck with.
If you dispute any portion of the bill, even "you are charging me for services never performed", they send it to a collection agency, The collection agency black mails you into paying by telling you that if you don't pay them off, they will destroy your credit, and they will.

Everyone justifies the highest fees by pointing out that they use the "overage" to pay for people who cannot afford to pay anything, those that need medical help who have no assets to loose thru bankruptcy, or won't be adversely affected by bad credit.

Plus, whenever possible, whatever is done is kicked to the next higher paying classification (code). That is one method to receive more finds for services from Medicare, HMOs, Insurance companies, and people who cannot afford insurance.

There isn't much you can do to have the hospital lower what they charge you. They will not lower whatever a doctor charges you.
Don't be surprised if the collection company magically turns your debt into a charge on a new credit card you've never applied for.

Remember that any any entity you contact for help has a vested interest not to reduce the funds you send to them.

If your insurance company won't help you, you can try writing a letter to your State's Attorney General asking them to check into the hospital's predatory billing practices and forward a copy to the hospital's CEO and the CEO of the holding company which owns the hospital.

If the hospital is out of your state, expect a reply telling you to pay the bill and take them to court in their state.

Unfortunately, you are firmly implanted in the USA's fragmented, socialized medical system.

Bob
 
#6 ·
A couple of years ago my son had to have a minor operation on his ear. The anesthesiologist sent a bill that was about 3X the "normal and customary". The hospital where the operation took place was part of our plan, however, the anesthesiologists where not. I told them that I would refuse to pay the excessive fees and would agree only to the "normal and customary" when they told me that wasn't acceptable I said fine. Just send me the paperwork where I authorized their doctor to perform any services on my son!

I complained to the hospital numerous times about how they could allow anyone to work in their facility that would not agree to the terms of the insurance plan and also not identify themselves as an independent contractor who would be submitting their own bill. I finally got a call back from the Hospital after about a month and they agreed. I had never authorized the anesthesiologist to perform any services, only the hospital. They asked if I would agree to the "normal and customary" charges and I told them that was all I ever asked for in the first place.

Ask them to send you the paperwork where you authorized them to perform any services for you, not where you authorized the hospital but the doctor or his company personally since he is the one trying to bill you.

My guess is that you never did.

Good Luck,
Kevin
 
#8 ·
Here in Texas and Louisiana, I was "informed" each time my family members had surgery.. as well as this past Monday when I had my own surgery in Texas... that there would be separate filing from the anestesiologists(sp?) and doctor(s)...

I was able to have it "preapproved" and paid my co-pay.... will have to wait for all the "stuff" to settle out...

Each surgery the last 15 years, we got bills from the hospital and doctor saying..
Actual price/negotiated price. The difference was "written off" by the hospital.

I know this doesn't speak to or help your problem... but it defines part of the "problem"...

Doctors are supposed to do that.

Accountants are supposed to do that.

Collection agencies are supposed to do that.

Payee's (us) are supposed to do that.
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx

Now, everyone knows you can't make a contract under duress.
 
#9 ·
I had a similar situation a few years ago, here's how you handle it. Every medical procedure has a corresponding CPT code. Depending on your area of the country, the US government pays a particular dollar amount to reimburse doctors and hospitals for medicare patients. Essentially, this price is what the government is willing to pay for any given procedure. The CPT price is a good starting point for negotiating you bill out of the stratosphere. Insurance companies basically agree with hospitals and doctors to create a "public" fee structure that the public sees, but it's not what they contractually agree to pay. What they agree to pay is a much lower price than what YOU see on your bill. Quite frankly, the whole system is so screwy, they should scrap it and start over again. Long story short, if you pay the invoice received, the issuer is thrilled. Understand that if you were a medicare patient, the company would gladly accept less money for EXACTLY the same procedure.....anything over-and-above that is gravy. I worked a $6,000, two hour ER visit down to $1,300, which represented 20% over the CPT price, which I felt was fair since it was an ER visit, and I understand ER visits are more expensive due to full staffing, etc... but when the CPT price for a scan is $280, yet they're charging me $1,800, it's nuts. Your insurance company isn't going to pay them $1,800 for a scan, so the entities basically agree to document an inflated price despite the fact that they have a negotiated lower price of reimbursement...probably around the CPT price, which you as the customer are not supposed to be aware of.

Happy to help you out if you want to contact me.
 
#10 ·
Medical billing horror stories abound.

I had a ride in an ambulance from hospital A to hospital B for a specialized procedure that hospital A wasn't equipped to perform. Got in the back of the van, spent the 30 minute ride just talking with the EMT in back.
When the bill arrived, I was charged an additional $300 for "oxygen". Hmm, didn't know I was being charged to breath the same air the EMT was. When I called the ambulance billing dept and told them that I had not received any oxygen during my trip, I was told it was a standard charge. I told them it was my standard policy not to pay for something I never got, and would see them in court for false billing if they wanted. I got an "adjustment" on the bill.
 
#11 ·
You definitely need to talk to your insurance company and an attorney. My understanding is that they are on the hook for ALL emergency billings - hospital, doctors, labs, regardless. That is the risk that the insurance company takes when they sign you up and take your check - you may have treatment in a facility with doctors not on their plan in an emergency situation.

If you are sent to collection, get an attorney and sue the hospital, the doctors and the collection agency.

I know we all scream too much litigation but it just gets ridiculous after a while and it gets to a point where they push us up against a wall.
 
#12 ·
So, I have learned a new term this morning..."reasonable and customary". I have found out the reasonable and customary amounts that Aetna pays in each case and are advising in writing the medical providors what the amount is and that I will pay any difference between what Aetna pays and what their normal payout amount is (20% in these cases...its "out of network" but being an accident they will bump the amount thay pay from 70% up to 80%).

So I'll let you know how this strategy goes.

Many thanks everyone.
 
#14 ·
cfell said:
My "waking thought" is.. "so, what "medical coverage" will REALLY be adequate" and if it exists, WHERE do you purchase..if you can afford it.
That's easy: don't get sick. Other than that, you're on your own. :)
 
#15 ·
How much?....I/company was paying $1,000/month just for me. I don't know many people that pay more. Then you still get stuck with this.
 
#16 ·
Send them a dollar a month till the end of time. It worked for me. Postage has gone up, but it has kept them off my back.
 
#17 ·
How did you word this to them when you proposed it...I can't imagine they agreed to "I'll pay $1 a month until this 3,000 is paid off.". That is after all 250 years.
 
#18 ·
I don't think anyone has addressed this issue yet; but if you have I'm sorry. The "out of network" is the issue. Yes, in an emergency most insurance companies will pay at the same rate as "in network". The problem with your case is that in a network all the participants have agreed to take what the insurance company has said they will pay. Out of network is different because there are no contractually agreed to prices by the hospital and doctors. Therefore there are no "write-offs" because no one has agreed to them. So, you're pretty much held responsible for the costs. I believe that, if you look closely at any paperwork you signed, it will say that, while the providers may bill the insurance companies as an accomodation, you, the patient is still responsible for all costs incurred. I'm not justifying the charges, just trying to explain.
 
#19 ·
Got a kidney stone while traveling thru Florida......
E.R. took my insurance info......(triple covered)
Spent a total of 6 hrs in the hosp. they stuck a tube in me and sent me home to get it fixed..................
Months later, got a bills for $10,000
They sent it to collection never billed me or sent to my insurance
Fight, fight, fight,.......
Finally one of my insurance companys made out the claim themselves from the info they had and paid most.......
Oh yes, another $5,000 to get the job finished at home.............................
 
#20 ·
$1,600 per hour.....that seems fair :brick:

STARFIGHTER said:
Got a kidney stone while traveling thru Florida......
E.R. took my insurance info......(triple covered)
Spent a total of 6 hrs in the hosp. they stuck a tube in me and sent me home to get it fixed..................
Months later, got a bills for $10,000
They sent it to collection never billed me or sent to my insurance
Fight, fight, fight,.......
Finally one of my insurance companys made out the claim themselves from the info they had and paid most.......
Oh yes, another $5,000 to get the job finished at home.............................
 
#21 ·
copilot said:
The "out of network" is the issue.
This is why we have attorneys. The key here is that this was an emergency situation. It is not like you simply decided to treat with a provider over an approved/contracted provider.

If you have a heath and accident plan and get into an accident out of state and have to receive emergency treatment and your insurance company does not pay, then you don't have to buy anymore lottery tickets because you just hit the bad faith jackpot. If you were sold a policy that says that you are not covered in those situations then you should sue the idiot who sold you the policy because basically you got a "depends on where you get hurt" insurance policy.

Insurance companies are like bookies. They are betting that the amounts that they take in are less than the amounts they pay out (sound principle for any company) and trust me you can't build skyscrapers and invest in foreign countries if you are not a company that is making a good deal of profit. Distilled further concerning their policy holders - they are betting that collectively they will not pay out more than the premiums they are taking in on all of their policies. One of the gambles they make is that an insured is going to need care "out of network" or however else you want to explain it and when that happens they have to bear the risk/downside of their bet.

If they are not covering an insured because he treated out of network in an emergency situation, then they are basically saying you have insurance as long as you are lucky enough to get banged up in an area of the country where there are contracted providers. So what are you paying for then? It is not like you had the opportunity to look up your emergency hospital or doctors or labs and see if they are in your insurance book before they started putting you back together.
 
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