Celebrating 10 years! 2007-2017

Hospital never ran insurance card

I have a family member who was in the hospital a few years a orange903/17/17
Request the itemized statement. Provide that to the insuranc agentdalecooper03/17/17
Wouldn't the insurance company likely deny the claim as unti tacocheese04/06/17
In what state did this occur? If it is NY, you may want t johnyquest03/18/17
Are you covered by an HMO or a PPO? Different rules apply. guyingorillasuit03/18/17
My first kid was free. severian203/18/17
It is a common misconception that insurance cards get "run" onehell03/30/17
Very informative, thanks. Is this true of all hospital physi lazlo03/31/17
The problem has been around for a while. My dad had issues qdllc03/30/17
"if the hospital takes your plan (in network) everyone who d onehell03/30/17
Well, since medical services are essentially contracts, that qdllc03/31/17
If providers who have contracted with a list of health insur onehell03/31/17
My brother had a similar situation like this but eventually jackiechiles03/30/17
Well, if you're in Minnesota: 62Q.75, subd 3. Unless mnjd03/31/17
That just means they have to submit the claim, and they have onehell03/31/17
Medical billing can be such a scam: https://www.nytimes.c associatex04/06/17
Yeah, it's crazy how people with no insurance get charged mo onehell04/07/17
orange9 (Mar 17, 2017 - 3:59 pm)

I have a family member who was in the hospital a few years ago. The hospital took the insurance information during intake. My family member also required imaging to be done while at the hospital.

This family member just received a bill from a collections company, without ever receiving any sort of bill. Turns out, the imaging at the hospital is a 3rd party, and the insurance information was never communicated. The imaging company is now saying since it is in collections, it is not their responsibility. And collections is saying we are not in the business of billing insurance companies.

Anyone ever deal with this?

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agentdalecooper (Mar 17, 2017 - 4:19 pm)

Request the itemized statement. Provide that to the insurance company. For the most part yeah, it is patient responsibility in the US to make third party payors cough it up. The info the agencies actually have to provide is far more limited than most people assume. Get in contact with the hospital to get the signed consent forms, billing, further itemizations.

You can try to hassle or headache the agency into closing it, but this can backfire if the provider has a downline legal vendor who sues the accounts.

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tacocheese (Apr 6, 2017 - 4:43 pm)

Wouldn't the insurance company likely deny the claim as untimely at this point?

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johnyquest (Mar 18, 2017 - 6:23 am)

In what state did this occur?

If it is NY, you may want to look at the Surprise Bill/Emergency Room Law, which requires notices/consents if there is a hospital which is in an insurance plan but radiologist who is out.

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guyingorillasuit (Mar 18, 2017 - 9:42 am)

Are you covered by an HMO or a PPO? Different rules apply.

Also, don't ignore the adverse effects this may have on your credit history. You shouldn't have to incur a hit because of a bill you didn't know about. Pull your credit history (free on creditkarma.com, and other sites). If you see the tradeline, write a letter to all 3 bureaus requesting a re-investigation, and send it certified mail/RRR.

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severian2 (Mar 18, 2017 - 12:22 pm)

My first kid was free.

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onehell (Mar 30, 2017 - 2:10 pm)

It is a common misconception that insurance cards get "run" like credit cards. They don't. It's an insurance policy and you make a claim. And just because a certain hospital is in your network, that doesn't mean that the outside parties they use for labs or imaging or even the actual physician who sees you are in the network. Every hospital visit will involve at least two claims: The "facility charge" and the "professional fee." Just because your insurance covers the former doesn't mean it covers the latter.

Think of a hospital as the owner of an office building and the doctors and other medical professionals (except for nurses and other support staff) as the tenants. They work AT the hospital, not FOR the hospital. Instead of charging flat rent to these tenants, the hospital gets a piece of the fees from the work the tenants bring in. This piece is called the "facility charge" and it covers the space the docs and other professionals work in, support staff like nurses and such, and the equipment the doctors get to use. The professionals, meanwhile, go through a "credentialing" process which results in them being given "privileges" to ply their trade in that hospital.

So if a hospital is in your insurance network, great, that just means the facility charge will be paid at in-network rates. You can (and often do) find yourself on your own with respect to the "professional fees" because you have no idea what providers you will actually see inside the hospital, what insurance networks they belong to, etc.

You need to bring the professional fee bill to your insurance company yourself, but don't be surprised if they don't cover it or only cover it at out-of-network rates, which results in substantial out-of-pocket expense.

In all likelihood, your family member did get a bill for the professional fees, but ignored it on the mistaken assumption that it would go through the same insurance process as the facility charge. It may have even been processed by the insurance company, which would send an Explanation of Benefits (EOB) explaining that the service is out of network and the provider is free to balance bill you. People often throw away these EOB documents as they are full of codes and jargon and are very difficult to understand. But the insurer should be able to tell you if they ever received a claim for this particular professional fee. If they did, don't be surprised if it was processed as an out of network service and this debt is actually an old "balance bill." Because if the professional is not in the network then they haven't agreed to accept the insurer's "usual and customary" rate for the service and can charge whatever they want. By the time the patient finally pays attention to this, it's gone to collections and they don't remember (and may not have ever read) all the paperwork they got preceding that.

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lazlo (Mar 31, 2017 - 2:48 pm)

Very informative, thanks. Is this true of all hospital physicians, or mainly specialsts? And is it different depending on non-profit or for-profit hospitals?

And about your comment about the lack of bargaining power of hospitals vs. 'rainmaker' doctors, do you know if in a city like Pittsburgh, where one hospital system (UPMC) is sucking up as many others as possible, whether that will change the balance?

Even superdocs may have to bend to consolidated insurance players, it's a jungle out there!

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qdllc (Mar 30, 2017 - 3:02 pm)

The problem has been around for a while. My dad had issues where random doctors were walking into patient rooms and billing for services rendered when they were not the physician assigned to that patient. Always double check the itemized version of your bill.

That said, if the hospital takes your plan (in network) everyone who deals with that hospital should be bound to what an in network provider will be paid. You can't shop around for service providers when in the hospital.

Just my 2 cents.

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onehell (Mar 30, 2017 - 3:29 pm)

"if the hospital takes your plan (in network) everyone who deals with that hospital should be bound to what an in network provider will be paid."

That does get discussed a lot but unfortunately, the hospitals do not have sufficient market leverage to demand this of docs, who can get privileged at pretty much whatever hospitals they want. So if one hospital demands it, the docs just go elsewhere and the hospital goes out of business. I've seen some hospitals that rely so heavily on some very expensive specialist bringing in the bacon that the departure of a single high-value surgeon could put them in the red. The docs, especially surgeons at the top of their field, have immense leverage to demand almost whatever they want. And what they don't want is to get treated like a W-2 employee subject to the whims of hospital administration. They are independent business owners who just use the hospital's space, staff and equipment which in turn allows the hospital to get the facility charges generated by that physician. And that's what the hospital lives on. And because most reasonably civilized areas have plenty of hospitals competing with one another, the hospital needs them more than they need the hospital; it's that simple. They will not tolerate the hospital telling them which insurers they have to contract with because they do not have to tolerate it.

It's yet another of the many problems caused by medicine being the one profession where demand exceeds supply by such a huge margin. And it would be tough to do this legislatively, because how do you tell some doc how to run his business? It would be easy to spin as yet more regulation of a poor small business private-practice doc. The lobbyists would be all over it and there could also be constitutional issues associated with the freedom to contract (or, in this case, not contract).

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qdllc (Mar 31, 2017 - 5:51 am)

Well, since medical services are essentially contracts, that a patient chooses a facility because it is in network should not work to his detriment when a service provider to the hospital is out of network.

If I'm admitted and need a MRI, I expect that the party doing the MRI is also in network. I don't have the capacity to check each provider to see if they are on the list.

That, or the facility should be responsible for lining up in network providers unless the patient specifically requests someone not in network.

It's not very different than having a patient sign an agreement to pay their bill plus interest when waiting to be admitted at the ER. If someone is in pain and being denied care until they sign forms, any resulting contact was formed under duress.

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onehell (Mar 31, 2017 - 3:46 pm)

If providers who have contracted with a list of health insurance companies that is a 1:1 match for the networks the hospital itself has joined do not exist in the geographic region, there's little to be done about that. You can't contract with someone who does not exist.

Essentially, I think you have a picture of the market that is upside down. If hospitals had a long list of people they could contract with and could pick and choose, then they would have leverage to insist that each provider they contract with join the same networks they are in. But again, this is not an employer choosing from a bunch of applicants. It's the exact opposite: A small number of doctors and other providers choosing which hospitals they will deign to work out of. The hospitals simply don't have the leverage to insist on this, as much as they might want to.

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jackiechiles (Mar 30, 2017 - 8:57 pm)

My brother had a similar situation like this but eventually got the insurance company to pay. He probably needs to call the hospital directly. Also, to write the debt collector asking for all records showing what he owes. Then have the insurer pay the hospital directly.

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mnjd (Mar 31, 2017 - 3:56 pm)

Well, if you're in Minnesota:

62Q.75, subd 3.

Unless otherwise provided by contract, by section 16A.124, subdivision 4a, or by federal law, the health care providers and facilities specified in subdivision 2 must submit their charges to a health plan company or third-party administrator within six months from the date of service or the date the health care provider knew or was informed of the correct name and address of the responsible health plan company or third-party administrator, whichever is later. A health care provider or facility that does not make an initial submission of charges within the six-month period shall not be reimbursed for the charge and may not collect the charge from the recipient of the service or any other payer.

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onehell (Mar 31, 2017 - 4:44 pm)

That just means they have to submit the claim, and they have to do it within 6 months. It doesn't require the provider to actually be in the network of whatever insurer the patient happens to have, which I suspect is the real genesis of OP's problem.

The deductibles and out of pocket maximums are often eye-wateringly high for out of network claims. And even if you have met the deductible the insurer will only pay its "usual and customary" rate for the service, less your 20% coinsurance, and of course an out-of-network provider has not contracted to accept that rate and is free to charge whatever it wants and "balance bill" you for the difference. So it is entirely possible to see a big claim from an out of network provider that the insurer pays nothing on, even if it is submitted to the insurer.

OP, meanwhile, is looking at this for a family member, and family members often don't give you the whole story. I suspect that they got a hard-to-understand EOB where the insurance essentially pays nothing (or far less than the billed charge because the OON provider doesn't have to accept the insurer's rate) and tossed that EOB years ago.

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associatex (Apr 6, 2017 - 1:01 am)

Medical billing can be such a scam:

https://www.nytimes.com/2017/03/29/magazine/those-indecipherable-medical-bills-theyre-one-reason-health-care-costs-so-much.html

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onehell (Apr 7, 2017 - 6:20 pm)

Yeah, it's crazy how people with no insurance get charged more than people who have it (because people without it don't get the negotiated rate regardless of whether the insurance is actually paying for something (e.g. because deductible has not yet been met). This is why it is wrongheaded for people to focus so much on deductibles: Even if all you can afford is a high-deductible plan, the insurance will save you money before it pays a dime just because of the rates that in-network providers have agreed to limit their charges to. And for out-of-network, there's still an out-of-pocket maximum after which the insurance will keep you out of the poorhouse. People focus way too much on deductibles and way underestimate the value of policies when those deductibles are high.

That said, I can't figure out why this lady didn't just file for bankruptcy. Even if she had nonexempt assets that would have precluded a chapter 7, all those years she spent fighting with them could have been spent paying off just a fraction of the debt through a chapter 13 plan and then getting the rest discharged after a few years in that plan.

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