I just don't understand ER billing....

[Michael Donahue]

Hey folks. Let me just start by saying I mean in no way to engage in a political conversation, but I can't for the life of me understand how insurance companies and hospitals come up with their billing rules.

I received a bill from the ER recently and I'm so frustrated I can't think straight. I required 8 stitches on my hand one day and it became infected so I went back the next day. This was over the weekend and I couldn't have just gone to my regular doctor.

FYI I'm rounding the number but you'll get the gist. The total hospital bill for both days was about $1000 and this is what they told me would have been my bill if I had no insurance. But my insurance company "allows" $900 per visit so the hospital "adjusted" my bill so that the total due was $1800. It literally just says adjustment on the subject line of the itemized bill and the number is the difference between the billed amount and the $900 allowance. The insurance company paid about $900 and now I have to pay the remaining $900. I understand that there are copays and I will have some financial responsibility, but if I pay everything due on my invoice the hospital will have received $1800 on a $1000 bill because I have insurance! The insurance only lowered my out of pocket expenses by $100!!!

How can they adjust a bill because I have insurance? Can I just pay them the difference between the original billed amount ($1000) and what the insurance company has already paid($900ish)? In in Connecticut if that matters. I just don't see how they can expect more money from me than they would have from some uninsured guy on the street.

I'm I just out of luck?? I really don't have an extra $900 sitting around and if I did I would have spent it on wood or something!! :D

[Greg Cuetara]

Michael,
Not sure what kind of insurance you have. Typically you will have an office co-pay and a co-pay for the ER. You should only be responsible for the co-pay for the ER. I would think since it was not two different incidents that it would be covered under one co-pay.

But again it all depends on your insurance. How long ago did this happen? I was sick a while back and I made a rule that I would not touch a medical bill less than 6 months old. The hospitals / doctors / insurance would duke it out and try to pit me in the middle and get me to pay the difference and double bill etc. I figured out that after about 6mo. the insurance company had duked it out with the medical people and that that was all I had to pay.

I would not say you are out of luck but I would certainlly get your insurance on the phone to review the bill and go over it with them and if you have to go into the billing office at the hospital and talk to them about it.

I jsut went back and re-read it and it says your insurance allows 900 per day so they should pay the 1800 not just 900. If the insurance considers this one incident, which they probably do and is why they are only paying 900, so should the hospital. A lot of times hospitals and doctors try to confuse the patient into paying something they dont' really owe so that they get money from the insurance co. and also the patient...it is called double billing and is illegal in many states...not sure about CT though.

Good Luck and let us know how it turns out. Again talk to the different parties involved and make sure everyone is on the same page.

Greg

[Michael Donahue]

Michael,
Not sure what kind of insurance you have. Typically you will have an office co-pay and a co-pay for the ER. You should only be responsible for the co-pay for the ER. I would think since it was not two different incidents that it would be covered under one co-pay.

But again it all depends on your insurance. How long ago did this happen? I was sick a while back and I made a rule that I would not touch a medical bill less than 6 months old. The hospitals / doctors / insurance would duke it out and try to pit me in the middle and get me to pay the difference and double bill etc. I figured out that after about 6mo. the insurance company had duked it out with the medical people and that that was all I had to pay.

I would not say you are out of luck but I would certainlly get your insurance on the phone to review the bill and go over it with them and if you have to go into the billing office at the hospital and talk to them about it.

I jsut went back and re-read it and it says your insurance allows 900 per day so they should pay the 1800 not just 900. If the insurance considers this one incident, which they probably do and is why they are only paying 900, so should the hospital. A lot of times hospitals and doctors try to confuse the patient into paying something they dont' really owe so that they get money from the insurance co. and also the patient...it is called double billing and is illegal in many states...not sure about CT though.

Good Luck and let us know how it turns out. Again talk to the different parties involved and make sure everyone is on the same page.

Greg

Thanks for the advice. The incidents were on 8/9 and 8/10. I know it also looks like double billing but that's just a coincidence of me rounding off the numbers to make it a bit easier. I do have 2 separate bills with different amounts due.

Even if $900/incident were allowed, why would the hospital expect the whole thing if they didn't perform $900 worth of billable services? It's like you have a $900 credit card, buy $400 worth of stuff, and then the card issuer wants $900 in payment. It shouldn't work that way!!!!

[Ed Hazel]

Thats part of the problem medical billing is to complicated also all of the billing is done after the fact. I wish I could build something and sell it and then tell he buyer the price with no return policy.

[Phil Thien]

First, check w/ the insurance company that there isn't some simple misunderstanding. If the hospital is attempting to get $1800 for $1000 of work, I would write them (hospital) the following letter:

Dear Sirs:

I understand that your organization wishes to "work the system" in order to maximize reimbursement from my insurance company.

However, if $1000 is the usual and customary fee for the services I received, is not billing and attempting to collect $1800 criminally fraudulent?

I am including $100, which is the balance of the amount you are owed for the services rendered.

I am forwarding this letter and supporting documents to CMS [Centers for Medicare and Medicaid Services], as well as my elected officials in Washington. You gotta be bilking taxpayers for millions. I hope the auditors leave no rock unturned.

If you follow-up and send the documents off to Washington, there is at least a chance that the hospital will undergo an audit. There is a new program whereby auditing outfits are getting hired to audit hospitals on a contingency basis. CMS and congress are loving the results. Here, read this:

http://www.ama-assn.org/amednews/2008/07/07/gvsa0707.htm

[Greg Peterson]

I'm still trying to figure out just exactly what health insurance companies (all five of them) bring to the table.

I had some physical therapy earlier this year. I called and asked what the rates would be. I was told it would be $88 per fifteen minute session. Some quick math and I was looking at over $1,600 dollars. :eek:

My bill through the insurance company was substantially lower.

Obviously the insurance company, who also owns the hospital, had a different rate than a walk in.

[Bonnie Campbell]

Hospitals will bill you whatever they can. My husband passed away January 6th. Before the end of that month I had a bill from the hospital for over $1,000! My husband had medicare AND a supplemental insurance. Fortunately for me I knew his bill was covered 100%. Hmmm, what better way to raise revenue than by billing a recent widow, she's in a fog and won't know. I don't know who in the hospital was going to benefit, but someone had a scam going. When I called to get an explanation about the bill, get this, they wanted to talk to my husband. I told her that'd be kind of hard since he DIED at THEIR hospital. I sat on the phone for a half hour getting the bill straightened out. Finally she looked it up on their computer, the bill HAD been paid in full.

Doctor offices are no better in how they charge insured and cash patients. I had a nice conversation with a woman in a waiting room this past year. We both were coming in for the same shot. Since she had insurance she was being billed $136. I paid my bill in cash and my shot was $66. Go figure that one out.

[Josh Reet]

My wife's pregnancy created a number of these sorts of issues and I had to waste a lot of time dealing with them. Now, I have a computer job and work out of my house, so I had the time and availability to sit on hold and get people to make the changes. But every time I did I felt bad for the guys working 9-5 factory jobs trying to get off a few minutes early so they could run to the billing department of the hospital before they close (at 4:30) or getting into the insurance phone system in time. That has got to be impossible.

[Ken Fitzgerald]

Folks,

You are certainly welcome to post based on your experience.

Political commentary and opinions are against the TOSs. Please refrain from such actions.

[Mitchell Andrus]

I was sick a while back and I made a rule that I would not touch a medical bill less than 6 months old.


2 years after surgery, I had a $650.00 appear from the doctor. He said he forgot to bill it and the insurance co said they don't take invoices that old. There was no justification for the charge, I think he though I would just pay it.

I told him what the ins co said and to take me to court if he though he had a case for collection. He stopped sending the bill (quarterly) after 10 years had passed.

Maybe after that long he could finally write it off as uncollectible.
.

[Karl Brogger]

Since she had insurance she was being billed $136. I paid my bill in cash and my shot was $66. Go figure that one out.

This is always been my experience. When paying cash for a clinic visit its always been pretty reasonable.

I think next time my pickup needs an oil change, or a set of tires I'm going to turn it in on my auto policy. That's the problem folks, people turn everything into their health insurance provider and wonder why its so expensive. I haven't had insurance for over five years now, I don't think I've spent over $3000 in that time going to the doctor, and that includes a $2000 trip to the dentist a few months ago. I should have a major medical plan should something, well, major happen, but I don't. I know my health insurance for just me through my last employer was about $230/month. Across five years that’s almost $14k! I can get a major medical policy for less than $100 a month, not subsidized, in any way.

[Chris Kennedy]

I used to do insurance billing for a medical office, so maybe I can shed a little bit of light on this. Realize that I did this a long time ago, so my knowledge may not be completely up to date.

First, with rates being lower for the uninsured compared to what is billed to the insurance company -- there is a tendency to use the income from insured patients to subsidize the uninsured. Not saying its right or wrong, but it is often the case.

Second, pay no hospital or provider bill until you receive an explanation-of-benefits from the insurance company. If there is any agreement between the hospital and the insurance company (preferred provider, hospital owned by the insurance company, etc.) there will be an explanation of the allowable charges by the hospital that you MAY be responsible for (it doesn't mean you are). If there is a preferred provider contract between them, generally any excess beyond co-pay has to be written off by the provider.

Third, you are entitled for an itemized bill for services and equipment. When you have the EOB from the insurance company, it should explain what was covered for each service. If the remaining balance is the `"adjusted" $900, you have grounds for a complaint and can challenge the bill.

Cheers,

Chris

[Orion Henderson]

Like someone else said-wait at least 6 months. I live in CT and am pretty sure double billing is illegal. That doesn't really mean much; they would just say it was a mistake and not a deliberate thing. We got double billed from the childrens hospital last winter. My wife called the insurance company and the hospital to resolve it.

[John Schreiber]

First, wait at least two months for all the bills and insurance statements to come through. (Usually there's no penalty so long as you pay within 90 days, but check and make sure.)

Take the time to figure out, as much as you can, exactly what the bills and statements say. This can be nearly impossible.

All the people you will talk to are reasonable people trying to do their jobs to the best of their ability. Treat them well. Their job is confusing and difficult. Document all conversations including the name of each person you contact and the time of the call. Remember that they are doing their best but their job is to maximize payment to the hospital or minimize expenses for the insurer.

Call the hospital and confirm that you understand what the bills say.

Call the insurance company and confirm that you understand what they are willing to pay.

Study your plan documents. Keep in mind that the summary which may have is not an official document. You may have to get the original. You will probably have to contact the insurance company to get clarification. Their interpretation will favor them as much as possible, but it isn't necessarily correct.

If it makes sense at this point, go ahead and pay the remainder. If it doesn't make sense, get on the phone again and ask them to explain. Be respectful and as nice as you can, but be insistent. Don't get put in the position of relaying information from the provider to the insurance company. Insist that they contact each other. Provide the names of the people you have talked to so they can talk to the same people. If the people you talk to aren't forthcoming or reasonable, ask to speak to their supervisors.

If it makes sense now, pay the remainder. If it doesn't make sense, go to the person who negotiated the policy with the insurance company. That will usually be the benefits person at your employer or the person who sold you the policy. Ask for their help in understanding the situation and ask them to advocate for you with their contacts.

Be nice but insistent all the way through the process. Document everything.

I've had to do this twice in the last year. It took a lot of my time and frustration and it took a lot of their time and frustration, but I got a reasonable solution each time. (Actually one is still in process, but I think it will be solved.)

[Greg Peterson]

The consensus seems to be that medical billing has the potential to overcharge the customer, whether this is intentional or unintentional is another matter.

I can not begin to imagine the added stress and strain of trying to decipher, organize and maintain this tenicled monster while trying to recover from a major medical issue like cancer.

Suffering a major health issue can be bad enough, but then having to worry about the financial implications, which is a reality for most of us -whether we realize it or not - seems to me counter productive.

I get a knot in my stomach every time I get mail from a health care provider or insurance company. To say I read their document with great skeptisism is an understatement. I pray I never have a major medical issue.

[Ken Fitzgerald]

We went through it when the LOML had cancer.

You get through it. It's not fun....it's not pretty......and it will anger most people.....but you get through it.

[Matt Meiser]

and it will anger most people

Makes my blood boil, that's for sure. I JUST got off the phone with a person fairly high up in the organization that our doctor is part of. Apparently my anger at their billing error that resulted in 2 $20 copays being sent to collection before we'd ever seen a bill came through in conversations with people below her. They are writing them off due to my "pain an suffering" All I wanted was an itemized bill, but OK. :confused:

[Greg Muller]

Seems the consensus here is off a bit on this one.

The insurance company guarantees a certain amount to the hospital for each procedure as part of their contract. This amount may be more than the hospital actually would bill you if you had a different insurance or were uninsured.

This is done so that the insurance company meets the contract on an annual basis, and so they don't have to pay out of their profits.

These amounts are dictated by the insurance company, NOT your hospital. Your hospital can only bill you according to contract, no more, no less.

Another explanation could be that you went to a hospital that is out of network for you.

Sounds like you need to talk to your insurance company.



If you think this is bad, just wait until the new legislation passes...this isn't a political thread, so I won't go into detail, but as a part of my job, I review contracts between 7 major hospitals and the insurance companies. These facilities stopped accepting United HealthCare insurance totally because they were overbilling patients, and underpaying the hospitals per contract and pocketing the differences. Don't believe me? Follow the $$$. Look at their P&L for the last year. There's plenty of info on the web about it, also. Many consumer protection agencies have blistered UHC for their practices.

.

[Greg Peterson]

Ken - As I said, the whole process is counter-productive. It unnecessarily places a burden on a person and their family that already has their hands full with healing/recovering from a major disruption in their lives.

Recovering from cancer is bad enough. Having to keep the insurance company honest is an extremely unfair burden.

[Cliff Rohrabacher]

Call the Billing office ask to speak to who ever is in charge and offer to settle for 65% of the sum demanded in one payment that day.

[Doug Shepard]

I'm still fighting 2 bills for an ER visit and an MRI to the tune of about $1300 total. The hospital says they're still looking into it but may just decide that I owe it, and they dont accept my dispute as legitimate. But I went into ER with a broken hip and extreme pain, barely able to walk. They X-rayed it, claimed it wasn't broken but I had probably bruised the bone and sent me home. So, having a history of 2 ruptured discs and suspecting since the hip wasn't broken that maybe I had another disc problem and the pain was all due to sciatic and pinched nerve, my regular doc orders a lumbar MRI which of course shows Nada. 3 weeks after breaking the hip, an MRI on the hip is finally done and voila, I have a broken hip. The surgeon that did the replacement looked at the original Xrays from the first ER visit and says the break was visible and the damage at that time wasn't as bad. After trying to hobble around on a "bruised" hip for 3 weeks it was pretty well trashed. So I've paid for the final hip MRI, the 2nd visit to ER when I was finally admitted, and the resulting hospital stay and hip replacement surgery. But I refuse to pay for the first ER visit or the unnecessary lumbar MRI without a fight.

[Cliff Rohrabacher]

I'm still fighting 2 bills [..] ER [..] MRI [..]t $1300 total. [..] they dont accept my dispute as legitimate. But I went into ER with a broken hip and extreme pain, barely able to walk. They X-rayed it, claimed it wasn't broken but I had probably bruised the bone and sent me home. [..] regular doc orders a lumbar MRI which of course shows Nada. 3 weeks after breaking the hip, an MRI on the hip is finally done and voila, I have a broken hip. The surgeon that did the replacement looked at the original Xrays from the first ER visit and says the break was visible and the damage at that time wasn't as bad. After trying to hobble around on a "bruised" hip for 3 weeks it was pretty well trashed. So I've paid for the final hip MRI, the 2nd visit to ER when I was finally admitted, and the resulting hospital stay and hip replacement surgery. But I refuse to pay for the first ER visit or the unnecessary lumbar MRI without a fight.

How do you spell m-a-l-p-r-a-c-t-i-c-e?
Get a lawyer. Send them a letter that they'll know is from you because it'll be a summons and complaint.

[Doug Shepard]

How do you spell m-a-l-p-r-a-c-t-i-c-e?
Get a lawyer. Send them a letter that they'll know is from you because it'll be a summons and complaint.

I've dropped the hint with them that if they pursue payment from me that I'm going to do that and that it's going to cost them much more than the amount they're trying to bill me for. But I'd otherwise just like to put the whole experience behind me and avoid the hassle of a lawsuit.

[Anthony Scira]

My daughter 4 years old have pneumonia a VERY serious one that landed der in the pediatric ICU for a 2 week stay. 2 chest tubes and a surgery to clear her lung and recovery the bill came out to a whopping 160,000 dollars. Insurance settled for 60,000 dollars.

I don't get how they do that.........

[Greg Cuetara]

I don't get how they do that.........

The basic premise is that all billed costs are based upon medicare payments. For example it might actually cost a hospital $20 but they bill it out at $100 hoping, just hoping, that medicare will actually pay them 25% to 50% of the $100 so in the end they will still make some money or that they will be able to make up for those who do not pay or for the procedures which medicare does not cover. With this in mind there is a huge markup so they can settle or they can contract certain rates out to insurance companies and still make out in the end. I know in Maine that the State owes hospitals about 500 - 600 million and the feds owe hospitals almost a trillion which I think the hospitals said they would forgoe 500 billion in medicare payments. Someone has to make payroll and in the end it is us who can pay. What I don't really understand is that if you can't afford it, it gets written off but if you have any potential of payment you are driven into the ground to take every last penny. Dont' want a free ride but there has to be a happy medium.

[Cliff Rohrabacher]

I've dropped the hint with them that if they pursue payment from me that I'm going to do that and that it's going to cost them much more than the amount they're trying to bill me for. But I'd otherwise just like to put the whole experience behind me and avoid the hassle of a lawsuit.

A lawyer letter will cost you no more than $300.00 and shouldn't cost more than $150.00

They will sit up and notice you a lot more if you are represented.

[Mark Hix]

I handle this stuff in my daily life. I see the "dual" amounts all the time. I imagine your first billing was not an itemized statement but a bill. Usually, the itimezed charges will show a discount for cash. It is illegal to charge seperate rates for the insured and the uninsured. Hospitals get around it by listing the "discount" on the bill.

Insurance companies pay according to a couple of different criteria. The first is if the hospital is under contract with the health care provider. (PPO situation) If so, they have an agreed apon price and that is want they charge and pay.

Insurance companies track charges by zip code for every kind of proceedure by every kind of doctor. They then use this information to determine what is "usual and customary". They use this to base payments. If for example your plan says 80% of usual and customary and your doctor charges $200 for an office visit that the average doctor providing the same office visit in your area charges $100 for, they your insurance pays 80% of the $100.

Without knowing anything about your insurance plan, my first advise is to know what your plan says. Is it a straight percentage of U & C or a PPO? If it was a PPO, were you in network? My health care coverage pays differently for a life and death emergency than it does for a suture job. If I need minor stitches, it cost me $15 for the doc in the box places or $100 for the ER.

You also need to look at the bill to see if the ER physician is included in the bill. In alot of cases, they are not. It depends on the hospital/state.

You also need to closely examine the itemized charges. You never know what will show up on the itemized charges. Be sure everything they charged for was a service that they provided. Some will amaze you. I have seen ER bills w/ pregneny test charges for males.

If in the end, if you owe the additional charges, you need to know that hospitals negotiate. They do it all the time. If you negotiate a settlement of the bill, ask them to fax you a confirmation.

[Matt Meiser]

You also need to closely examine the itemized charges. You never know what will show up on the itemized charges. Be sure everything they charged for was a service that they provided. Some will amaze you. I have seen ER bills w/ pregneny test charges for males.

Coding errors are common. I had had a bill for an MRI rejected by insurance several years ago as because the procedure didn't fit the diagnosis. When I called, it was because they billed for my ankle MRI because of shoulder pain. :rolleyes:

We've found at least 3 billing errors from all my medical bills from this summer so far. We have dual insurance and that seems to be causing a fair amount of confusion--failure to bill the secondary, failure to bill write off the amounts over the allowable, etc. Luckily everything from the surgery center got billed correctly--since my wife is the business manager and the biller works for her, I'm sure she was extra careful.

[Stan Johnsey]

Do y'all understand why we need healthcare reform?

[Greg Peterson]

Many, if not most hospitals are privately owned. They are not public institutions. so not only do they have payroll to meet, they have owners that demand a profit.

Good thing we don't expect our fire or police departments to generate a profit.

[David G Baker]

Greg P,
There was a local area volunteer fire department that was in the news recently that got caught trying to generate a profit by over stating their calls, having crews in two places at the same time and got caught with a lot of porn on the in house computer. So far the local police department hasn't been caught.
I have had similar problems described by Matt M but have always followed up on them and ended up getting the charges paid by the insurance company.

[Greg Peterson]

I have had similar problems described by Matt M but have always followed up on them and ended up getting the charges paid by the insurance company.

David - Inflating the numbers to pad the budget is one thing, and dishonest at best.

When someone is tasked with the job of getting recovered from a major illness/injury, their recovery is unnecessarily taxed by having to keep the hospital and insurance company honest.

Why should the consumer have to guard against fraud in health care billing? I expect a used car salesman to get one over on me, but why is it acceptable to allow hospitals and insurance companies to engage in fraudulent billing practices, intentional or otherwise?

Just because that is the way it is doesn't make it right.