• Go to page :
  • 1 23
  • Text Only
Voting History
rated:
I'm not sure if this is the right forum or not.

I recently had an outpatient surgery, which required general anesthesia, but was otherwise about as simple of a surgery can be (15 minutes worth). The total bill was around $7000. Does anyone know the best way to fight such a bill? Can hospitals charge $50 for a single dose of Percocet?

I'm actually a physician (Internal Medicine - Hospitalist). I understand OR's are expensive, as well as other hospital facilities, but all of the miscellaneous chargers are absolutely ridiculous. All of this makes me wonder what people do who have no medical knowledge & get a huge bill for all sorts of things that they have no clue about. I'm sure many people don't know what else to do, and just pay what they are told to pay.

I have a nice income, but I'm sure there are many honest, hard working, poor people who have had their financial lives destroyed by excessive medical bills.

Our healthcare system is in absolute shambles. Many people don't pay a penny, many people pay way too much for it, many get rich off of healthcare who have no business profiting from it, and the current sagging system is going to completely implode sometime soon. It's a "Non-winning" political issue, so politicians run from it.

Sorry about the rant.

So, does anyone know the most effective way to get a hospital lower a bill that seems to be excessive?


Member Summary
Most Recent Posts
First of all capping doctor's pay at 120K which by the way is the average for your general internist/pediatrician curren... (more)

lakerjock (Feb. 16, 2007 @ 4:52p) |

<blockquote><hr>I had surgery a few months ago. The surgery took approximately 1 1/2 hours. The total bill from the surg... (more)

elm33 (Feb. 16, 2007 @ 6:26p) |

Thanks for reviewing my bill. I found the letter from the insurance company that predated the EOB and I uploaded it to y... (more)

mas1205 (Feb. 16, 2007 @ 11:40p) |

Quick Summary is created and edited by users like you... Add FAQ's, Links and other Relevant Information by clicking the edit button in the lower right hand corner of this message.
Thanks for visiting FatWallet.com. Join for free to remove this ad.

Depends on if you have insurance

file a complaint
doesn't really matter what you complain about

I forgot to say that I do have insurance that pays 80%, the other 20% is my part.

As for the people who don't have insurance, I believe that many times these folks actually pay more because hospitals cut deals with big insurance companies & charge them less.

nevus said: [Q]I forgot to say that I do have insurance that pays 80%, the other 20% is my part.

As for the people who don't have insurance, I believe that many times these folks actually pay more because hospitals cut deals with big insurance companies & charge them less.

but hospitals will cut the "retail" price in half for uninsured if they pay something

You'll find a number of threads on this if you search for [medical bills] or [negotiate hospital] or something similar.

Here, for example, is one discussion kicked off by SIS of a service called "My Medical Control" that negotiates them for you and takes a cut of the savings.

Two posts down, lostdude notes a resource published by Medicare listing all of the standard fees hospitals that accept Medicare are required to charge CMS: CMS Fee Schedule.

Take a poke around some of the other threads that show up.

HTH & GL. <img src="i/expressions/face-icon-small-smile.gif" border=0>

devildoc said: [Q]nevus said: [Q]I forgot to say that I do have insurance that pays 80%, the other 20% is my part.

As for the people who don't have insurance, I believe that many times these folks actually pay more because hospitals cut deals with big insurance companies & charge them less.

but hospitals will cut the "retail" price in half for uninsured if they pay something


Yeah, they definately negotiate if they don't think they are going to get anything.

nevus said: [Q]As for the people who don't have insurance, I believe that many times these folks actually pay more because hospitals cut deals with big insurance companies & charge them less.You're a doctor, yet are completely ignorant of the basic, well-publicized reasons why our health system is considered to be broken?

That's exactly right, but for those that don't have insurance...they have a better chance of reducing the bill. Especially if the use a company that helps with bill review. There was a post dealing with this that I remember reading, and that gave a lot of very interesting facts and suggestions.

Only Suckers Pay Retail
David Whelan 11.27.06
Forbes

How to chop hundreds of dollars off your medical bills.

The cost of a medical procedure is usually a mystery until the bill comes. That's when you really get sick. Craig Conn, a software consultant in St. Charles, Ill., recently got an invoice for his wife's surgery, including a $3,390 facility charge. Conn is especially attuned to his medical bills because his insurance from Blue Cross Blue Shield of Illinois has a very high $5,000 deductible. Even though Blue Cross negotiated a lower facility charge of $1,290, Conn still thought it was too high.

So he turned to a company called My Medical Control. A negotiator at the Louisville, Ky. firm compared what Conn had been charged with the lowest rates in the Chicago area. Then the negotiator called the hospital with an offer: Charge my client's credit card for $962 now and get your money within 48 hours. Or, and this was left unsaid, keep sending him reminders and hope to get paid someday, fingers crossed. The hospital agreed. My Medical Control pocketed 35% of the savings, or $115, and Conn was delighted to save $213.

Timothy Cahill, My Medical Control's founder, is the first to admit his two-year-old business takes advantage of what might be charitably called a screwy medical economy. Three million U.S. employees have now been shifted to high-deductible plans, often saving their employers on premiums, but patients who now bear more cost still don't get enough information about what they should be paying for services and procedures.

So a lot of the time they don't pay. Last year the cost of uncompensated care reached $29 billion, up from $22 billion in 2000. That shows up on the big hospital chains' profit-and-loss statements, where bad debt levels have almost doubled to 10% of revenue since 2000. Cahill's last two companies were a lot like My Medical Control: One helped health insurers get money out of hospitals and doctors, the other helped hospitals collect from car insurers. "What we've done," says Cahill, "is put ourselves in the middle."

My Medical Control has six negotiators who run bills through a database that analyzes the 12,000 commonly used medical codes and checks them against a wide range of reimbursement policies in 200 metropolitan areas. If a customer is not getting the lowest rate, the negotiator calls the hospital or doctor's office and uses that rate to make a lowball offer. The average bill received is $1,000, and Cahill typically gets clients a 22% haircut. The largest bill ever was $62,000, which Cahill's company cut in half. Half of hospitals agree to the offer, nine in ten doctor's offices go for it. Cahill acknowledges that a smart patient could chisel down a bill without his help, but then you'd have to see a doctor for the migraine you'd get.

Link to Forbes Article

SIS posted a link on a company that does the haggling for you but I can't find it.

Well, welcome to our life, Doc.

My Dad passed away late last year and he stay in the hospital for 2 weeks. Emergency room, emergency room doctor, interal med doctor, surgery room, surgery doctor, pathologist, medical lab, ambulance (for trx to nursing home), cancer doctor, radiation cancer doctor, room charge, MRI, Bone Scan, Ultrasound, ICU charge... I'm getting about 2 bills per week still from people/place I never heard of...

OT: It about time doctors get to know the system they work in. I ask a doctor once on the cost of a procedure, not the whole thing, just out of pocket and he had no idea, neither does his office staff.

doerrb said: [Q]You'll find a number of threads on this if you search for [medical bills] or [negotiate hospital] something similar.

Here, for example, is one discussion kicked off by SIS of a service called "My Medical Control" that negotiates them for you and takes a cut of the savings.

Two posts down, lostdude notes a resource published by Medicare listing all of the standard fees hospitals that accept Medicare are charged: CMS Fee Schedule.

Take a poke around some of the other threads that show up.

HTH & GL. <img src="i/expressions/face-icon-small-smile.gif" border=0>


Thanks, that's some great info.

Glitch99 said: [Q]nevus said: [Q]As for the people who don't have insurance, I believe that many times these folks actually pay more because hospitals cut deals with big insurance companies & charge them less.You're a doctor, yet are completely ignorant of the basic, well-publicized reasons why our health system is considered to be broken?

My post would have been way too long. There are so many reasons our system is broken. If I stated five reasons, people would criticize me for not mentioning 15 more (and rightfully so). Where should I start?

nevus said: [Q]There are so many reasons our system is broken. If I stated five reasons, people would criticize me for not mentioning 15 more (and rightfully so). Where should I start?In Off Topic. <img src="i/expressions/face-icon-small-smile.gif" border=0>

lostdude said: [Q]SIS posted a link on a company that does the haggling for you but I can't find it.

Well, welcome to our life, Doc.

My Dad passed away late last year and he stay in the hospital for 2 weeks. Emergency room, emergency room doctor, interal med doctor, surgery room, surgery doctor, pathologist, medical lab, ambulance (for trx to nursing home), cancer doctor, radiation cancer doctor, room charge, MRI, Bone Scan, Ultrasound, ICU charge... I'm getting about 2 bills per week still from people/place I never heard of...

OT: It about time doctors get to know the system they work in. I ask a doctor once on the cost of a procedure, not the whole thing, just out of pocket and he had no idea, neither does his office staff.

Unfortunately, the whole system has gotten so complex that 99% of doctors aren't going to know. Hospitals & insurance companies, not physicians, determine the price of things. The main place where doctors figure in is the zillion unnecessary tests ordered just to protect their own backside. Also, docs prescribe WAY too many drugs. People have no idea.

I would encourage anyone to ask their doctor WHY he's ordering some of the tests he's ordering. If he can't give a succinct, straightforward, common language answer, then somethings wrong with that picture.

Next time try performing the surgery yourself. While the risks are higher the money saved is pure profit paid to yourself!

We had $15k in out of pocket expenses due to benign PVCs discovered during a C-section. I had to pay for a room in the ICU (yes the ICU not the telemetry floor) and a room in the maternity ward. I needed nasal spray during my stay and we were billed $40 for saline spray. This was with 80/20 BCBS of IL too.

The health care consumer must educate themselves about conditions. There are more then enough sources available. This way they can tell if their doctors course of action seems proper for the condition.

It seems to me that the only way this will change is a threat to a socialistic health care system or eliminate health insurance PACs.

nevus said: [Q]
I would encourage anyone to ask their doctor WHY he's ordering some of the tests he's ordering. If he can't give a succinct, straightforward, common language answer, then somethings wrong with that picture.

Doctor's order tests/bloodwork because they CANT tell by looking at you if you are dying inside. I would tell everyone that if your doctor doesn't run tests on you to find a new doctor. I work in the Medical Lab Industry so I may be baised, but I see first hand way too many.. WAY WAY WAY TOO many doctors who don't adopt new testing and practice old medicine. For example a standard Lipid is going to give you a 30-40% chance to detect a patient who has some kind of heart disease, a newer 2x as expensive test is above 80%. Docs dont order it on patients because it costs the healthcare industry more $, or they just like old medicine. So that patient has a preventable heart attack and ends up in the hospital with bills in the $10k range.... Cost savings?

Anyways.. I just get upset when I see a doctor suggest that patients question doctor's on why they are running tests. They are running tests to save your life. You can't look in someone's ear and tell them they are 100% healthy. You run tests.

Something you can do straight away is go over the bills (it sounds like you have some detailed ones) and look for anything that shouldn't be there. $50 for a dose of percocet is an even worse price if you weren't given any.

VzwSpiker said: [Q]Anyways.. I just get upset when I see a doctor suggest that patients question doctor's on why they are running tests.
I think you should always ask why a doctor is running tests (or prescribing a medicine or recommending a course of action). It doesn't mean you have to decline the test (especially not based on price alone) but you need to know what's being done.

As someone who works in medical insurance I have read this thread and am at a total loss of understanding here.

[quote]
I recently had an outpatient surgery, which required general anesthesia, but was otherwise about as simple of a surgery can be (15 minutes worth). The total bill was around $7000. Does anyone know the best way to fight such a bill? Can hospitals charge $50 for a single dose of Percocet?


"I forgot to say that I do have insurance that pays 80%, the other 20% is my part."
[/quote]

Now that I have that from the OP up there lets continue.

1. Facilities do not charge for anesthesia. That would not come on your outpatient Surgical Facility Bill. That would be billed by an anesthesiologist seperately and possibly also by a CRNA. (sometimes they split the reimbursment of the procedure).

2. Most outpatient facilities are contracted for outpatient surgery using groupers (sometimes called case rates). There are typically exclusions in a contract (example, implants are typically excluded i.e. pacemaker) that would be paid outside the contracted surgical rate. With that said your percocet would normally be reimbursed as part of the surgical case rate, not seperately. Hence, you should not have any out of pocket expenses on that drug. Finally I do want to clarify that if you were seen at a large, popular, well respected facility there is chance that they are contracted at a discount of billed charges. If that is the case that is unfortunate. Large facilities have the power to negotiate much better contracts with insurance companies than smaller facilities. Example of that would be Johns Hopkins or The Mayo Clinic.

3. Anesthesiologists are considered "blind providers." IE, you do not choose your anesthesiologist and you have no control over whether not they are contracted with your insurance company. The insurance company will not hold you responsible for this.

4. If your coinsurance percentage is 20%, that would mean that your portion of this doctor bill is $1400.00. That number seems dubious since you originally stated "the total bill was $7000.00" i.e. billed charges. You would only pay co-insurance on 20% of the contracted rate.

At most (80%) of the outpatient hospitals out there billing on average of $7000.00 the average reimbursment of that facility would be somewhere in the neighborhood of $500.00 to $1500.00 after the contract had been applied to the claim. Even if the contracted rate for the procedure was $1500.00 then the 20% coinsurance portion would be $300.00.

As someone who is working at a hospital in the medical field I can hardly believe you could be so ignorant of how the system works.

Concerning fighting your bill:
You should call your insurance company and ask them a couple of questions.

1. Was the anesthesiologist contracted, or non-contracted and reimbursed at the Usual & Customary/Reasonable & Customary rate or billed charges. You see since the anesthesiologist is typically non par, and also a blind provider, if they start to balance bill you then your insurance company in turn would adjust the claim to pay billed charges since the selection of this provider was beyond any control mechanism that you have. A lot of people do not realize this and just blindly pay their medical bills.

2. What was the facility reimbursed for my procedure? By determining this, you can determine what the contracted rate was. simply add whatever the reimbursment was plus your copay/coinsurance/deductible portion = the insurance companies contracted rate. Then review what the facility is billing you for. You may be suprised to find that hospitals and doctors alike favorite thing to do is balance bill people for the difference between the insurance companies contracted rate, and the facilities billed charges. Not only is this sneaky, snide, etc.. it is totally illegal.

3. Finally, request for all of your claims to be reviewed for adjustment if you feel that your portion of the bill is too high. You would be suprised by the number of claims that are paid wrong due to auto-adjudication systems, poorly written contracts, and poorly trained employees.

If you have any doctors balance billing you that were ancillary to the facility visit (the anesthesiologist is a good example) request the insurance company to pay them billed charges. Since the services provided were ancillary to your surgical event, which I am sure you had performed at a contracted facility (if you did not, you deserve to pay it all out of pocket yourself) request for all providers that are balance billing you to be paid at billed charges, not the u&c/r&c rate. That is your right and the insurance company will do it.

Remember. Understanding your benefits is the key to success. Simply following the rules of your insurance plan (seeing contracted providers) and being pro-active about any bills you receive will probably save you more money than any medical negotiation service.

Finally, isn't this forum for finance deals?





elm33 said: [Q]

Finally, isn't this forum for finance deals?

The title doesn't say Finance deals. It say Finance. It is a board spectrum and this is a valid post because this particular subject usually has a large impact on ones finances especially as they age.

The doctors point isn't that (s)he doesn't understand their insurance, they are outraged by the costs. Very valid and now many doctors are in network for insurance reasons. This needs to be addressed.

I am glad this topic was brought up. My husband fell off a ladder and broke his wrist in 8 places plus other bruises. He had to go to emergency and have surgery on the wrist. The doctor's bill was $2200. The hospital's bill was $15,095.69. He did not stay overnight. We were shocked...not ever dreaming the bill could be so high. We have no medical insurance but do not qualify for any help. We pay what we can each month. Even the doctor was shocked at how the hospital bill was. I see we need to look into this....try to get it reduced if possible.

when my wife gave birth last year the hostital and the OBGYN office both offered 20 % savings right on their bill if you pay now. Saved my $130 of a $650 copayment. They did not do that with the other two deliveries.

My wife recently had a CAT scan. The amount billed to insurance was over $2,000. Insurance negotiated rate was about $250.

That, in a nutshell, is what's wrong. The prices charged bear no rational relationship to what the provider collects. This means that whomever gets stuck without insurance likely winds up with a serious financial problem.

nevus said: [Q]My post would have been way too long. There are so many reasons our system is broken. If I stated five reasons, people would criticize me for not mentioning 15 more (and rightfully so). Where should I start?Sorry, I didnt mean to criticize in that way. Your post seemed to have the tone that this was a new eye-opening experience that shocked you, when you work as part of the system and the inequities/disfunctions are routinely publicized.

Hospitals and medical labs should be required to charge everyone the same for the same service. I would favor a requirement that the prices be posted for the public to exam. By the way, this crazy system has actually been molded by government regulations and programs such as medicare.

[Q]The title doesn't say Finance deals. It say Finance. It is a board spectrum and this is a valid post because this particular subject usually has a large impact on ones finances especially as they age.


You are right. I couldn't resist that due to the post regarding the Finance forums and Finance deals yesterday. I agree this is a worthy topic, however I think the OP has not given us the whole story. There is a big difference between billed charges, and what he/she should actually be paying coinsurance on. I would like to hear more from the OP about his original situation to make better comments. I would also like to hear more about his insurance benefits.

BCBS is a non profit company (I know thats a hard one to swallow right there) .. I deal with them daily and although I find their EOPs ridiculously hard to understand for the layman, I also find they are reputable and typically do their business fairly well and fairly honest.

I also can hardly believe a a resident doctor would not have a better understanding of how much the simplest procedure can cost.

I deal with providers all the time and 99% of them are very well informed regarding their contracts with insurance companies, the insurance companies policies and so forth. Any large insurance company at this point would have a access point on the internet for providers to research into their own claims and so on. It just seems unlikely to me that this $7000 bill should come as any suprise to the OP.

The same person who is "outraged by the cost" is 50% of the problem. Doctors charge these ridiculously high fees for service. How can a doctor be at all taken aback by this?




You could also request an audit of your hospital bill.

I was referred to have urgent surgery done at the ER awhile back (since the surgeon I was originally referred to was unavailable at the time). The surgeon was shocked and furious when he found out how much the ER had charged me. My primary care physician and the surgeon complained to as high as the CFO of the hospital but they wouldn't budge. I talked to the Director of Patient Care about the situation and she agreed to have my bill audited while I was present. They went over every charge and explained what procedure it was for...

Turned out they had charged me for x-rays and services that were never performed. <img src="i/expressions/face-icon-small-disgusted.gif" border=0> Needless to say, that shaved quite a bit off my bill.

elm33 said: [Q]
I also can hardly believe a a resident doctor would not have a better understanding of how much the simplest procedure can cost.


I posted this thread not just b/c I wanted info on how to best address my particular issue, but also b/c I know there are many people here who are greatly affected by this type of issue.

I should have resisted the temptation to get off topic, which I started to do in the original post. That was a mistake. I have learned.

This thread is only productive if the main topic is not strayed from.

To answer the above statement, I'm a general internist. I have no idea how much a surgical procedure costs. Physicians don't know everything despite what some physicians would lead you to believe.

My issue is with all of the misc. charges from the hospital which I have no idea how they can justify. I am all for paying taxes. I am all for donating to worthy charities. IMHO in our current system, for-profit hospitals shouldn't be robbing from people who pay, to pay for those who don't. With some of the good advice above I am going to do some research on what the procedure "should cost" or the best guestimate.



I feel terrible about the woman above who was stuck with a big bill because her physician managed the situation inappropriately (sending her to the ICU for no good reason). IMO, the hospital should have clearly written off that portion of the bill. Also, the hospital administration should have then reprimanded the physician. Unfortunately, 99.99% of people wouldn't push the hospital to do that. If really pressed, there is no way I can fathom the hospital not waving off the inappropriate ICU cost.

elm33 said: [Q]

The same person who is "outraged by the cost" is 50% of the problem. Doctors charge these ridiculously high fees for service. How can a doctor be at all taken aback by this?

There have been numerous examples in this thread of doctors not knowing the true charges. Maybe it is less common then you realize?

nevus said: [Q] I feel terrible about the woman above who was stuck with a big bill because her physician managed the situation inappropriately (sending her to the ICU for no good reason). IMO, the hospital should have clearly written off that portion of the bill. Also, the hospital administration should have then reprimanded the physician. Unfortunately, 99.99% of people wouldn't push the hospital to do that. If really pressed, there is no way I can fathom the hospital not waving off the inappropriate ICU cost.

The thing about this situation is that I never saw the cardiologist in person the night I was sent to the ICU. All I received was an EKG and monitoring in the post op room. I saw the cardiologist for 2 minutes after they preformed all tests and sent me back to the maternity ward.

Truly, that is not as bad as the closer hospital where I went in with a very bad rash. I had a 130 heart rate on and off for 2 hours. The doctor refused to listen to me about the decongestant that I had taken for the last 3 days and forced me to stay. I had to sign out against medical advice, the rash was never looked at and I was charged for a room visit. It was all cleared up with my PCP a few days later.

Why can't Congress pass a law to send the hospital bills of all the undocumented illegals to Mexico. Then they can reimburse us with barrels of oil and thus keep our gasoline prices low. The whole system su*cks! You're here illegally you get free care but if you're a hardworking American, you're screwed in everyway possible.

[Q]There have been numerous examples in this thread of doctors not knowing the true charges. Maybe it is less common then you realize?

Well in all honestly I think some people have been mislead by their doctor. It is very possible the doctors were acting clueless so they did not look like they were victimizing their patients. If you want to be realistic about it most doctors become doctors for 1 of 2 reasons. I think more often its a little of both. 1st reason: They want to help people. What a noble cause. 2nd reason: They want to be financially secure.

In my day to day work I function as a liason between the insurance company and the providers. I am their service partner. If they have a problem or a request I typically handle it for my book of business. It is fair to say that I do not always deal directly with the doctor themselves, I would say more often than not I deal with their billing staff. This doesn't change the fact that when a doctor becomes a "contracted provider" they are made well aware of what the contracted rates will be for any given service. They are made well aware of what will be denied, what will be paid, and so forth. For facilities, they are exceptionally aware of what their costs are for services as the negotiate these contracts.

Any hospital visit whether it be emergency room, observation, outpatient surgery, or inpatient care will be accompanied by a whole slew of ancillary claims. I concede that doctor x may not be aware that the hospital they are working in is charging $5000.00 for 10 miligrams of epogen (dialysis drug) however, doctor x will be submitting their own claim for their personal services in regards to the patient. Whether it is them doing a check in on you in an inpatient setting, or the lab techs doing your lab work, all of those things create seperate ancillary claims.

All of those folks are acutely aware of what they are being paid. Its their business to know. I do not think that most people get up and go to work everyday with no clue as to how much reimbursement they are receiving for there services. It would be a kin to you going to your office job and having no idea what your pay scale was. Its unrealistic. People want to make money, and they want to know how much they are making.

The doctor may not be aware of what the hospital charges, and the hospital may not be aware of what the doctor charges, however--they are both aware of what they charge individually. Make no mistake.


In my experience, hospital billing are based upon the medical procedure was performed on patient. in your case it would be general anesthesia, which can be billed at an inflated price as high as $7,000 so that when it submit claim to 3rd party, it will ensure overbilled rather than underbill the plan even the procedure may just costs only $500. The insurance plan may pay as little as $1800 or less. In your case, your copay would be 20% of $1800 (if this is your insurance agreement with hospital). Unfortunately, this inflated price hurts innocent uninsured patients when it automatically bills them with inflated price without adjustment.

For medicaid and medicare patients, the hospital can't charge more than the plan pays for even the patients pay out of the pocket. For those cash or out of pocket patients, you can call billing department asking for supervisor or senior staffs to look at for adjustment or beg for reduction or ask to get enrolled in medical assistance program (medicaid, medicare, uninsured assistance programs, etc..). If you are not eligible then call consumer advocate helpline in your city or state. Since patient weren't explained of the billing prior to receive treatment, you can fight this in court for fraud untold patients of the charge or and citing the payment excessive incomparison to patients with private insurance.

In addressing your question that hospital charge $50/pill on percocet. Hospital doesn't charge patient for drug services as pharmacy. They only charge you for medical services including drugs in its service. Percocet are pretty cheap average roughly about $11/100tablets depending on strengths.

My advice is that you call up hospital and have them bill your insurance, your insurance will tell them how much your 20% out of pocket cost is. What happened a lot of time that is billing personel bill incorrectly due to wrong information or the hospital does not have contract with your plan. In either way, they will have to submit that claim to your insurance on your behalf, once that clear, the insurance will tell hospital to charge you the balance 20%, I am pretty sure that the copay will be less than $1400.

I have my wife got the same billing from Pavillion Presby-Columbia in NYC for anesthia service when she gave birth, they billed as high as $7,000 then reduced to $3500, my plan only pays $1350.

I am a pharmacist, practicing in New York, I hope above the information helps you.

[Q]The thing about this situation is that I never saw the cardiologist in person the night I was sent to the ICU. All I received was an EKG and monitoring in the post op room. I saw the cardiologist for 2 minutes after they preformed all tests and sent me back to the maternity ward.

I am curious and maybe I missed this but did you have medical insurance at the time? If you went to a participating facility and they put you in the ICU, that would require authorization from the insurance company for that high level of care. If the insurance company did not authorize that high level of care, the hospital cannot hold you liable due to their contract with the insurance company.
The hospital will try by way of balance billing the member and so forth, but if the member calls the insurance company and informs them of the hospitals actions the insurance company will see to it that the hospital stops.

It saddens me daily to see how many people get taken by doctors and hospitals. I admit that the insurance companies are the devil and are part of the problem, however we typically do not illegal extort money from our members via threatening letters, bad marks on your credit, law suits due to lack of payment, and so forth. This is all common practice for hospitals and doctors.

If you ever receive a bill from a provider that you were not expecting or that you do not agree with you should immediately call your insurance company and if you are not satisfied with the answer or the help you get just continue calling back and speaking with different representatives. Eventually you will get a tenured staff member with a wealth of experience that genuinely wants to help you.


And to add to bigman99's post above regarding the anesthesia--always remember they are blind providers and you had no choice but to use whatever anesthesilogist was assigned to you. The insurance company will adjust the payment to this provider on your behalf if the provider is balance billing you. The insurance company can only legally hold you liable for services provided by non par providers when you knowingly choose to see one. anesthesia providers are excluded from that due to the fact that no one knowingly chooses an anesthesia provider.

elm33 said: [Q]

I am curious and maybe I missed this but did you have medical insurance at the time? If you went to a participating facility and they put you in the ICU, that would require authorization from the insurance company for that high level of care. If the insurance company did not authorize that high level of care, the hospital cannot hold you liable due to their contract with the insurance company.
The hospital will try by way of balance billing the member and so forth, but if the member calls the insurance company and informs them of the hospitals actions the insurance company will see to it that the hospital stops.

Yes, I did. There was a clause in that policy. If there is an "emergency" that needs immediate treatment, the doctor can go ahead and proceed. The insurer needs to know within 24 hours or they will not cover the costs.

I had no sleep, no food, vomited several times, was in labor all day, had surgery & experienced very high levels of anxiety because I never had any non-oral surgery before(much more awake during the procedure). This would cause anyone with this condition to experience PVCs.

[Q]Yes, I did. There was a clause in that policy. If there is an "emergency" that needs immediate treatment, the doctor can go ahead and proceed. The insurer needs to know within 24 hours or they will not cover the costs. I had no sleep, no food, vomited several times, was in labor all day, had surgery & experienced very high levels of anxiety because I never had any non-oral surgery before(much more awake during the procedure). This would cause anyone with this condition to experience PVCs.

Yes that is standard plan language and when received as a claim for payment this is what would typically happen:

The claim comes in and has a high level of care that requires an authorization. No authorization was assigned by the insurance company. This is where we hit the fork in the road to go either left or right.

If we go left: the insurance company requests medical records and notes regarding your case for review by a case manager to determine if they want to issue a retro-authorization for that level of care.

If we go right: The insurance company denies that level of care flat out without considering the circumstances. The level of care would be denied as "No authorization, Member held harmless (not liable)"

If you had to pay out of pocket on that and the hospital you were at was participating its time to call your insurance company and request and adjustment on your claim. They have a legally binding contract with the hospital and they are all very clear about level of care. "If we (insurance) do not authorize the level of care, but the hospital provides the level of care, then the hospital understands they will not be receiving payment for those services and they will not be able to bill the person those services were provided to." in other words, the member is held harmless.

It is for this very reason that you use to hear alot in the news about "the insurance companies playing doctor" because its really the insurance company that determines what level of care you are going to receive, not the doctors. They are able to do that because of their contracts with the facilities. The hospitals want to get paid so typically they will provide the level of care the insurance company is willing to pay for and nothing more. When they do provide a higher level of care without obtaining a pre-authorization then they understand that they are running the risk of either 0 reimbursement, or being reimbursed for a lower level of care instead. They also understand they cannot bill the member (but they do anyway).

What really puzzles me about this is it is federally mandated by the US government that for the first 3 days of inpatient care (normal child birth) and for the first 5 days of inpatient care (c-section) no authorization is required and the insurance company has to pay. That federal mandate also pertains to the level of care provided by the facility. If you were there and delivered there should be no question about auths or coverage and the stay should have been paid in full for the first 3 or 5 days without the need for the facility to obtain authorization.

If you had any out of pocket expense outside your standard copay/co-ins/deductible I urge you to call your insurance company and keep calling them until they fix this.

I wanted to mention also that every state has an insurance commissioner and they will help you fight problems you are having with your insurance company. Believe it or not they have quite a bit of power and they can cost the insurance company millions of dollars in fines and so forth if they deem their practices unfair. Texas and Georgia are notoriously hard on insurance companies and would like nothing better than to give them a hard time.

Skipping 62 Messages...
Thanks for reviewing my bill. I found the letter from the insurance company that predated the EOB and I uploaded it to yousendit in case you want to see it: http://download.yousendit.com/3721F28400749AAA

My insurance plan is a PPO. The facility was definitely out-of-network. The way that Aetna handles these claims is bizarre, but I'm used to it because I'm had hundreds of claims over the past two years as a result of a bad car accident.

Aetna used their determination of a reasonable and appropriate charge to calculate the payment it would make to the out-of-network facility. Aetna determined the reasonable amount to be $8,894.08. Because this is out-of-network, Aetna pays 70% (as opposed to 90% for in-network). The total payment was $7,559.28. The difference between the "reasonable amount" and the amount Aetna paid is the amount I am responsible for (for purposes of Aetna's calculation of whether I have met my out of network coinsurance for the year). So, even though as guarantor I could end up paying around $50,000 for this claim (the amount not paid by Aetna), Aetna considers only $1,334.80 toward meeting my $3,000 out of network coinsurance. If I had met the $3,000, then Aetna would have paid 100% of what it considers the reasonable charge (i.e., an extra $1,334.80. I think this is completely ridiculous, because I spent nearly $100,000 out of pocket this past year, but according to Aetna, based on its reasonable charges, I have not met the $3,000 deductible.

Global Claims Service told me to call them as soon as I receive the hospital bill. They told me not to pay the bill because by paying it they would loose leverage to negotiate a lower amount for me to pay.

I had three back surgeries this year. This one was complicated and the surgeon felt more comfortable at this particular facility. He said they had the best equipment and OR and because of the nature of the surgery I didn't want to take any risks and I wanted the surgeon to work in the place he was most comfortable. The other two surgeries were at in-network facilities.

All of the EOB's from Aetna look like this. I also had about 12 epidurals last year. For these procedures I had a hospital charge, anaestesiologist charge and medication charge. Even though the facility was in-network, I was left with a bill of about $1,700 for each procedure. And the bill simply stated "hospital incidentals" or "injectable medication" as the description.

Also, I have questioned Aetna about the placement of various codes on the EOB as well as why charges are broken down the way they are and why some are at 70% and others at 100%. The response was that it was internal calculation of the claim and it had no meaning and that I could ignore that. If I felt better I would argue more to get to the bottom of it, but for the time being I am concentrating my energy on getting better so I can resume my life.



Disclaimer: By providing links to other sites, FatWallet.com does not guarantee, approve or endorse the information or products available at these sites, nor does a link indicate any association with or endorsement by the linked site to FatWallet.com.

Thanks for visiting FatWallet.com. Join for free to remove this ad.

TRUSTe online privacy certification

While FatWallet makes every effort to post correct information, offers are subject to change without notice.
Some exclusions may apply based upon merchant policies.
© 1999-2014