Hospital Bill Nonsense [Appealing a hospital bill]

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Topic Author
creator
Posts: 15
Joined: Fri Sep 17, 2021 12:23 pm

Hospital Bill Nonsense [Appealing a hospital bill]

Post by creator »

I was reading this forum for a while now and I would like to ask this community for advise.

I recently had potentially serious medical symptoms. I call my primary doctor and I had an exam with them in the next hour. There was a potential risk of a serious medical condition so they referred me to the hospital for an ultrasound. I had it done the same day but not in ER.

A month later I received two bills for ~$1000 from the hospital (deductible + copay) and another bill of ~$50 from some other company for extremity study.

I didn't go to ER ($200 fee) to make it cheaper as it didn't even cross my mind that ultrasound from a hospital will not count as a specialist visit.

I've talked to the health insurance company and they confirmed that everything is as per the policy. The only remedy I have is to file an appeal with them. Basically avoiding ER (higher cost to insurance) generated higher costs to me.

I am in a position to pay the bill, but this is a question of principle. I do plan to file an appeal and would appreciate if you have any suggestions on what should be included. I am also outraged that a 15 minutes ultrasound non ER visit costs $1000+. I do understand that hospital has tons of expenses but isn't it a ripoff? What is the best strategy to lower the hospital bill? I haven't talked to them yet.

Thanks in advance for your suggestions.
fabdog
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Re: Hospital Bill Nonsense [Appealing a hospital bill]

Post by fabdog »

Why would an ultrasound (from a hospital or anywhere else) count as a specialist visit? Your plan has different coverage for a specialist visit?

If the bill from the hospital for the ultrasound has already been marked down to your plans negotiated rate, then that's what you have agreed to pay. DO you think it would have been cheaper to go thru the ER?

If the hospital billed you at out of network (full price) rates you can appeal and ask them to only pay your insurance companies negotiated rate.

And yes, there are cheaper places to get ultrasounds done. That's the issue with medical care... unless most everything else we buy it's not easy to compare options especially under the time pressure of a medical emergency

Hopefully it all worked out and you are in good health

Mike
AlohaBill
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Re: Hospital Bill Nonsense [Appealing a hospital bill]

Post by AlohaBill »

My hospital was for $613000. My insurance and Medicare paid a fraction of the cost. I my copay was $100. I was happy.
sport
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Re: Hospital Bill Nonsense [Appealing a hospital bill]

Post by sport »

You can always try to negotiate a lower payment. For example: "This is a large amount for me. If I pay you in full now, can you reduce the bill to $750? If they say yes, get it in writing.
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Artful Dodger
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Re: Hospital Bill Nonsense [Appealing a hospital bill]

Post by Artful Dodger »

Different ultrasounds will cost different amounts, but I recently had one and the total cost was $906. I'm on Medicare now, and the allowed amount was $103. So, I'd definitely check to make sure your PPO has repriced the bill before paying anything. I know Medicare will usually get a better deal, so you may not be getting a 88% discount. You may have had a more extensive test, and it could have had a much higher starting bill, but I would confirm first.
jgt808
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Re: Hospital Bill Nonsense [Appealing a hospital bill]

Post by jgt808 »

I work in a hospital radiology dept. I just finished paying my ultrasound bill from an ER visit in February. The $50 is likely the Radiologist reading, which is separate. If you are in a low income (175% or poverty level) or thereabouts, they may provide full assistance. Mine is Kaiser affilated. I was just outside the window, so I didn't qualify but they split my bill into 9 payments, with no interest. I remind myself, the ER saves lives each day. Stat CT/US/lab results, 24/7 staffing, brain and heart and ortho surgeons on call to save lives. I'm a small cog in that wheel and grateful for the accessibility. $2k bill sucks, hope they can help you better than me. I don't understand the billing, was it OUT of network that caused it?
DarkHelmetII
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Re: Hospital Bill Nonsense [Appealing a hospital bill]

Post by DarkHelmetII »

creator wrote: Fri Sep 17, 2021 12:50 pm I was reading this forum for a while now and I would like to ask this community for advise.

I recently had potentially serious medical symptoms. I call my primary doctor and I had an exam with them in the next hour. There was a potential risk of a serious medical condition so they referred me to the hospital for an ultrasound. I had it done the same day but not in ER.

A month later I received two bills for ~$1000 from the hospital (deductible + copay) and another bill of ~$50 from some other company for extremity study.

I didn't go to ER ($200 fee) to make it cheaper as it didn't even cross my mind that ultrasound from a hospital will not count as a specialist visit.

I've talked to the health insurance company and they confirmed that everything is as per the policy. The only remedy I have is to file an appeal with them. Basically avoiding ER (higher cost to insurance) generated higher costs to me.

I am in a position to pay the bill, but this is a question of principle. I do plan to file an appeal and would appreciate if you have any suggestions on what should be included. I am also outraged that a 15 minutes ultrasound non ER visit costs $1000+. I do understand that hospital has tons of expenses but isn't it a ripoff? What is the best strategy to lower the hospital bill? I haven't talked to them yet.

Thanks in advance for your suggestions.
1) For the existing bill, ask if they have a quick-pay discount. A major hospital near me offers a quick pay discount if you give them a credit card # over the phone. I have no idea if this going to be the case for this hospital but worth trying. And if not, perhaps call around to understand if offered by any other hospitals near you (for future reference).

2) For the future - I hear you, this type of stuff drives me nuts too. By doing what you thought was economically / socially responsible etc... by not occupying ER space sounds like you have gotten penalized, so to speak. But might just have to act selfishly rationally and do what is cheapest for you, unless you want to confront the entire albatross of the US healthcare system (beyond the scope of BH anyways).

3) A final, actionable thought on the existing bill:
a) Get CPT (procedure) and ICD-10 (diagnosis) codes. Push them for the actual, universally accepted codes, not internal codes that only make sense to that particular hospital. Google the codes and make sure they make sense ... this won't make you an expert but still make sure they didn't ultrasound your spleen and bill you for a leg ultrasound (or whatever the case may be).
b) Make sure the 'math' is correct in applying your deductible and co-pay and / or co-insurance
c) Verify if any of the charges are being bill as out-of-network, and if so, why
humblecoder
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Re: Hospital Bill Nonsense [Appealing a hospital bill]

Post by humblecoder »

creator wrote: Fri Sep 17, 2021 12:50 pm I didn't go to ER ($200 fee) to make it cheaper as it didn't even cross my mind that ultrasound from a hospital will not count as a specialist visit.
You are assuming that if you had gone to the ER, you would have only been charged $200. Is that a correct assumption though?

I know my insurance also charges an $X ER fee, but it isn't $X for "all you can eat" medical services. This is just the hospital fee for taking up space. I would also get billed separately by any doctors, for any meds, for any tests, etc. I know this because my daughter had to go to the ER a few years ago, and I paid the co-pay for the ER visit plus a slew of other bills for the actual services rendered.

Now it's possible that your insurance works differently than mine, but it is also possible that you are making an incorrect assumption on how your plan works. Something to think about before you pursue this further.
Topic Author
creator
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Re: Hospital Bill Nonsense [Appealing a hospital bill]

Post by creator »

Thanks, Mike. It was a false alarm, so I am doing great.

ER has only $200 copy and no deductible or coinsurance. So I could go to ER and it will cost me $200 and likely ~$3000 to the insurance company.
This will drive the cost for everyone and next time this is exactly what I will do. The system is screwed up.

The hospital is in network.
fabdog wrote: Fri Sep 17, 2021 1:44 pm Why would an ultrasound (from a hospital or anywhere else) count as a specialist visit? Your plan has different coverage for a specialist visit?

If the bill from the hospital for the ultrasound has already been marked down to your plans negotiated rate, then that's what you have agreed to pay. DO you think it would have been cheaper to go thru the ER?

If the hospital billed you at out of network (full price) rates you can appeal and ask them to only pay your insurance companies negotiated rate.

And yes, there are cheaper places to get ultrasounds done. That's the issue with medical care... unless most everything else we buy it's not easy to compare options especially under the time pressure of a medical emergency

Hopefully it all worked out and you are in good health

Mike
Topic Author
creator
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Re: Hospital Bill Nonsense [Appealing a hospital bill]

Post by creator »

Artful Dodger wrote: Fri Sep 17, 2021 2:36 pm Different ultrasounds will cost different amounts, but I recently had one and the total cost was $906. I'm on Medicare now, and the allowed amount was $103. So, I'd definitely check to make sure your PPO has repriced the bill before paying anything. I know Medicare will usually get a better deal, so you may not be getting a 88% discount. You may have had a more extensive test, and it could have had a much higher starting bill, but I would confirm first.
Yes, the insurance repriced it to in-network rate. It literally took 15 minutes for a test...
Topic Author
creator
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Re: Hospital Bill Nonsense [Appealing a hospital bill]

Post by creator »

Thanks for the info. In my case it was in-network hospital and not ER visit. However, the specialist located in the hospital.

The healthcare system saves lives like many other occupations. It is hard for me to be grateful for a complete lack of transparency in terms of pricing. There is no way 15 minute ultrasound should cost $1K+. If it does, it means the system is extremely inefficient and must be reformed.
jgt808 wrote: Fri Sep 17, 2021 3:03 pm I work in a hospital radiology dept. I just finished paying my ultrasound bill from an ER visit in February. The $50 is likely the Radiologist reading, which is separate. If you are in a low income (175% or poverty level) or thereabouts, they may provide full assistance. Mine is Kaiser affilated. I was just outside the window, so I didn't qualify but they split my bill into 9 payments, with no interest. I remind myself, the ER saves lives each day. Stat CT/US/lab results, 24/7 staffing, brain and heart and ortho surgeons on call to save lives. I'm a small cog in that wheel and grateful for the accessibility. $2k bill sucks, hope they can help you better than me. I don't understand the billing, was it OUT of network that caused it?
Topic Author
creator
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Re: Hospital Bill Nonsense [Appealing a hospital bill]

Post by creator »

Good point. I will need to confirm this with my health insurance company. Yes, we have a $200 ER copy on the insurance and previously this is only what we paid. My daughter MRI done in ER and we didn't get a separate bill.
humblecoder wrote: Fri Sep 17, 2021 3:44 pm
creator wrote: Fri Sep 17, 2021 12:50 pm I didn't go to ER ($200 fee) to make it cheaper as it didn't even cross my mind that ultrasound from a hospital will not count as a specialist visit.
You are assuming that if you had gone to the ER, you would have only been charged $200. Is that a correct assumption though?

I know my insurance also charges an $X ER fee, but it isn't $X for "all you can eat" medical services. This is just the hospital fee for taking up space. I would also get billed separately by any doctors, for any meds, for any tests, etc. I know this because my daughter had to go to the ER a few years ago, and I paid the co-pay for the ER visit plus a slew of other bills for the actual services rendered.

Now it's possible that your insurance works differently than mine, but it is also possible that you are making an incorrect assumption on how your plan works. Something to think about before you pursue this further.
notBobToo
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Re: Hospital Bill Nonsense [Appealing a hospital bill]

Post by notBobToo »

creator wrote: Fri Sep 17, 2021 12:50 pm I've talked to the health insurance company and they confirmed that everything is as per the policy. The only remedy I have is to file an appeal with them.
Sounds like yet another case of buyer's remorse. Did you choose a less expensive (premium) plan and now want relief for your balance due? What don't you understand about "...everything is as per the policy"? Your out of pocket is your out of pocket. Pay it and move on.

And no, $1000 for an ultrasound at a hospital is not out of the question, especially in 2021. I paid 2/3 of that at a hospital over 10 years ago. (Of course I learned then DO NOT GO TO HOSPITAL FOR NON-EMERGENCY ULTRASOUND.)
hershey102d
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Re: Hospital Bill Nonsense [Appealing a hospital bill]

Post by hershey102d »

AlohaBill wrote: Fri Sep 17, 2021 1:49 pm My hospital was for $613000. My insurance and Medicare paid a fraction of the cost. I my copay was $100. I was happy.
Assuming you intended three zeros . . . good grief.
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celia
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Re: Hospital Bill Nonsense [Appealing a hospital bill]

Post by celia »

Don’t pay anything until the insurance company(ies) pays.

The first thing they do is adjust the price according to the agreement they have with the hospitals/ doctors. When the Explanation Of Benefits (EOB) statement arrives, start by understanding every amount on it. The facility will bill separately than the doctor who interprets the image. (He/she may be in another location. Our X-rays and labs are usually processed about 60 miles away from where we live.)

Then, if you still have questions, call the insurance company.

Many people (even doctors we’ve talked to) don’t understand their insurance policy and what is covered and what is not. To be a better consumer, you need to start with understanding your insurance. Gathering information or attending a meeting at your employers’ next Open Enrollment event is a good place to start. You can even learn from questions that others ask, just like you can by reading this forum.
hoofaman
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Re: Hospital Bill Nonsense [Appealing a hospital bill]

Post by hoofaman »

My view on healthcare expenses costs is this, I have no idea what they will be, all I have any control over is who I choose for Health Insurance. And whatever my insurance out of pocket maximum is per year, that is the cost I plan to expect each and every year. If I’m under that number, it’s an unexpected bonus.
HomeStretch
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Re: Hospital Bill Nonsense [Appealing a hospital bill]

Post by HomeStretch »

Glad to hear you are recovered. My opinion would be to pay the patient portion per your insurer EOB for the services you were rendered. Next time (now that you know) choose the ER if that’s cheaper.

I agree that it’s frustrating that healthcare costs are not transparent and are expensive. However, for non-routine and emergency services, it’s impossible even in non-pandemic times to always get a price in advance to make the best financial decision. But it helps if you understand the provisions of your own policy. Given the pandemic, it’s hard to even obtain urgent care at providers/hospitals due to worker shortages, high occupancy, etc. So I am grateful to be able to receive timely routine and non-routine healthcare services. I am even more grateful to have insurance and to be able to afford the out-of-pocket costs.
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anon_investor
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Re: Hospital Bill Nonsense [Appealing a hospital bill]

Post by anon_investor »

sport wrote: Fri Sep 17, 2021 1:52 pm You can always try to negotiate a lower payment. For example: "This is a large amount for me. If I pay you in full now, can you reduce the bill to $750? If they say yes, get it in writing.
+1. OP should do this.
sport
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Re: Hospital Bill Nonsense [Appealing a hospital bill]

Post by sport »

hoofaman wrote: Fri Sep 17, 2021 4:29 pm My view on healthcare expenses costs is this, I have no idea what they will be, all I have any control over is who I choose for Health Insurance. And whatever my insurance out of pocket maximum is per year, that is the cost I plan to expect each and every year. If I’m under that number, it’s an unexpected bonus.
You can control some medical costs. In my area there is a medical center that is "associated" with a hospital, but is not actually part of the hospital. I can get lab tests, x-rays, mri, colonoscopy, sleep tests, etc. without paying the high price that such services would cost at the hospital. I recently had a colonoscopy there and they billed Medicare $1170 and they were paid $551. I believe it would have been more expensive at the hospital. There are also surgical centers available for outpatient surgeries which cost less than the hospital would charge. Related to this, our medical advantage plan encourages us to use these services rather than the hospital due to the cost savings.
veindoc
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Re: Hospital Bill Nonsense [Appealing a hospital bill]

Post by veindoc »

It’s likely related to a facility fee. If the outpatient clinic is associated with a hospital, you will be charged more than an office not associated with the hospital. You can google facility fee to learn more about the controversy behind the billing.
sport
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Re: Hospital Bill Nonsense [Appealing a hospital bill]

Post by sport »

veindoc wrote: Fri Sep 17, 2021 4:54 pm It’s likely related to a facility fee. If the outpatient clinic is associated with a hospital, you will be charged more than an office not associated with the hospital. You can google facility fee to learn more about the controversy behind the billing.
The outpatient clinic I went to does not charge facility fees. They are associated with, but not part of the hospital.
veindoc
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Re: Hospital Bill Nonsense [Appealing a hospital bill]

Post by veindoc »

sport wrote: Fri Sep 17, 2021 5:07 pm
veindoc wrote: Fri Sep 17, 2021 4:54 pm It’s likely related to a facility fee. If the outpatient clinic is associated with a hospital, you will be charged more than an office not associated with the hospital. You can google facility fee to learn more about the controversy behind the billing.
The outpatient clinic I went to does not charge facility fees. They are associated with, but not part of the hospital.
I would double check, especially if they are associated with the hospital. It’s a major issue in that many patients go to outpatient offices thinking they will be charged less but CMS allows hospitals to charge these additional fees in hospital associated outpatient offices.

Here is an article explaining this gotcha fee.

https://www.medicaleconomics.com/view/f ... ryone-pays

There is a huge effort to eliminate them, but the hospitals apparently have an effective lobby countering that effort.

I don’t know what kind of ultrasound you had. But as a vein doctor myself, if someone comes into my office (independent practice) for an ultrasound of the leg to check for a blood clot, CMS allows $250-$300. If my practice was associated with one of the area hospitals, CMS would allow for $1000. Same building, same technician, same study, same doctor, different affiliation (hospital associated outpatient office vs independent non hospital owned office), different prices.
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Wricha
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Re: Hospital Bill Nonsense [Appealing a hospital bill]

Post by Wricha »

I think your statement “ There was a potential risk of a serious medical condition so they referred me to the hospital for an ultrasound.” pretty much answers your question. Once you enter that facility you expected all the resources and expertise of that facility to be available to you in this potentially serious medical condition, which your PCP agreed. Just think how many people and expensive equipment were there for your emergency. Fortunately, you did not need anything more than to rule out a problem. $1k for ultrasound sounds cheap to me given all the people who were ready to help you.
Going to private free standing imaging center might of gotten you a cheaper ultrasound but had you needed anything else you would be paying that ER visit or an undertaker.
UALflyer
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Re: Hospital Bill Nonsense [Appealing a hospital bill]

Post by UALflyer »

creator wrote: Fri Sep 17, 2021 12:50 pmI didn't go to ER ($200 fee) to make it cheaper as it didn't even cross my mind that ultrasound from a hospital will not count as a specialist visit.
Visiting an outpatient facility for an imaging test never, ever counts as a specialist visit.
I've talked to the health insurance company and they confirmed that everything is as per the policy. The only remedy I have is to file an appeal with them. Basically avoiding ER (higher cost to insurance) generated higher costs to me.

I am in a position to pay the bill, but this is a question of principle. I do plan to file an appeal and would appreciate if you have any suggestions on what should be included. I am also outraged that a 15 minutes ultrasound non ER visit costs $1000+. I do understand that hospital has tons of expenses but isn't it a ripoff?
What's the basis for an appeal? Avoiding the ER may or may not have caused your out of pocket cost to be higher, but an appeal based on this basis will fail. Likewise, an argument that an outpatient imaging test should be considered a specialist visit will fail, as will an argument that a 15 minute test should result in a lower cost.

All that is adjudicated during a medical appeal is whether the claim was processed in accordance with your summary of benefits. In order words, in order to be successful, you need to reference specific mistakes, if any, associated with your claim in the specific context of your summary of benefits (the 100+ page long insurance contract that you have). The decision will also reference specific sections of your summary of benefits.
valleyrock
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Re: Hospital Bill Nonsense [Appealing a hospital bill]

Post by valleyrock »

I'm not sure from the foregoing whether you asked for a detailed billing statement from the hospital. That's not the
same as what they mail out with a bill requesting payment. That statement is yours for the asking, and could be helpful for understanding the situation and seeing if anything was off. It also can help to access the detailed insurance policy document, and not simply rely on what a representative says on the phone about coverage. They can be mistaken.

I encountered similar a similar issue to those described above. A colonoscopy done as an office visit was far less expensive than one done as a hospital visit, even a clinic not at the hospital, but affiliated with a hospital. One clinic I went to changed its billing to office visit because, I suspect, business went down when people figured it out. Anyway, these differences were clearly written in the policy, two different colonoscopy prices. My most recent one in a hospital involved at least 5 people in the room. I guess that's why they gave me propofol to knock me out so I wouldn't trip over anyone. Big business.
Luckywon
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Re: Hospital Bill Nonsense [Appealing a hospital bill]

Post by Luckywon »

creator wrote: Fri Sep 17, 2021 4:04 pm Good point. I will need to confirm this with my health insurance company. Yes, we have a $200 ER copy on the insurance and previously this is only what we paid. My daughter MRI done in ER and we didn't get a separate bill.
I am getting from your posts that you believe getting your ultrasound through the ER would have been cheaper because you would only be responsible for the ER fee of $200 and that would include an ultrasound if needed. And that your experience previously was that your daughter had an MRI through the ER that was included in the ER fee with no additional charges. This scenario is totally alien to my experience and understanding, and I'm a health care worker. Would you mind sharing what your insurance company is? Is this a PPO plan? HMO? Is this Kaiser?
BobTexas
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Re: Hospital Bill Nonsense [Appealing a hospital bill]

Post by BobTexas »

anon_investor wrote: Fri Sep 17, 2021 4:46 pm
sport wrote: Fri Sep 17, 2021 1:52 pm You can always try to negotiate a lower payment. For example: "This is a large amount for me. If I pay you in full now, can you reduce the bill to $750? If they say yes, get it in writing.
+1. OP should do this.
Agree. If they won’t negotiate the total, ask if they will do a no interest payment plan (ie divide the cost over 10 equal monthly payments)
AlohaBill
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Re: Hospital Bill Nonsense [Appealing a hospital bill]

Post by AlohaBill »

Yes, $613,000. $40,00 for three ambulances. I’m still alive and doing very well. My insurance and Medicare came through w/o them I think I would have been a dead man. However, I do feel a little like a dead man walking. BTW, the quality of my health professionals was super. I was able to have the surgery during the lull in this pandemic. I am not sure if I could have it now.
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creator
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Re: Hospital Bill Nonsense [Appealing a hospital bill]

Post by creator »

It is PPO through United HealthCare. I called them yesterday and they confirmed that procedures that are done during ER visit are fully covered by the plan and I will only need to pay $200 copy.
Luckywon wrote: Fri Sep 17, 2021 9:06 pm
creator wrote: Fri Sep 17, 2021 4:04 pm Good point. I will need to confirm this with my health insurance company. Yes, we have a $200 ER copy on the insurance and previously this is only what we paid. My daughter MRI done in ER and we didn't get a separate bill.
I am getting from your posts that you believe getting your ultrasound through the ER would have been cheaper because you would only be responsible for the ER fee of $200 and that would include an ultrasound if needed. And that your experience previously was that your daughter had an MRI through the ER that was included in the ER fee with no additional charges. This scenario is totally alien to my experience and understanding, and I'm a health care worker. Would you mind sharing what your insurance company is? Is this a PPO plan? HMO? Is this Kaiser?
Luckywon
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Re: Hospital Bill Nonsense [Appealing a hospital bill]

Post by Luckywon »

creator wrote: Sat Sep 18, 2021 11:46 am It is PPO through United HealthCare. I called them yesterday and they confirmed that procedures that are done during ER visit are fully covered by the plan and I will only need to pay $200 copy.
Luckywon wrote: Fri Sep 17, 2021 9:06 pm
creator wrote: Fri Sep 17, 2021 4:04 pm Good point. I will need to confirm this with my health insurance company. Yes, we have a $200 ER copy on the insurance and previously this is only what we paid. My daughter MRI done in ER and we didn't get a separate bill.
I am getting from your posts that you believe getting your ultrasound through the ER would have been cheaper because you would only be responsible for the ER fee of $200 and that would include an ultrasound if needed. And that your experience previously was that your daughter had an MRI through the ER that was included in the ER fee with no additional charges. This scenario is totally alien to my experience and understanding, and I'm a health care worker. Would you mind sharing what your insurance company is? Is this a PPO plan? HMO? Is this Kaiser?
I'm astonished. You learn something new every day. Thank you for clarifying that.
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creator
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Re: Hospital Bill Nonsense [Appealing a hospital bill]

Post by creator »

WOW, so many wrong conclusions and assumptions!

1. Buyer's remorse? The insurance gets $26K annually for our family plan! How much more do you think bloodsucking system should get from a family? Most of the premium is covered by employer, so there is no real option for us to shop around for the best plan as everything else will cost much more due to the regulations that allowed this system to exist. It is not a free market.
Or do you see yourself shopping around for an emergency procedure when you need it the same day and nobody knows what the actual cost will be? I've called insurance company and was on hold for an hour!

2. The policy is completely screwed up. It is cheaper for me to go to ER ($200 copy) as coinsurance and deductible will not apply in this case (confirmed with the insurance company yesterday). In this case the insurance company will be out $3K+ in this case and I will pay only $200. Instead I opted for a socially responsible way and now insurance pays ~$200 and I pay $1K+. I will be filing the appeal as this policy doesn't make sense. Oh, and yes, now I WILL GO to ER as a primary choice for urgent and semi-urgent care.

3. $1000 for a 15 minute ultrasound is insane. It was a scheduled hospital visit to a specialist who got less than $50 for a procedure in a separate bill. It was NOT ER visit. It only tells me that the system is absolutely not transparent and inefficient and must be reformed. If you overpaid it doesn't mean that the rest of us should overpay.

4. In my case IT WAS URGENT and there was a low risk of a blood clot (serious condition) based on the symptoms, so I needed the procedure done the same day. I WILL GO TO ER FOR THE SAME CONDITION OR MEDIUM URGENCY CONDITIONS FROM NOW. I'll pay less and it will cost much more for the whole system.

notBobToo wrote: Fri Sep 17, 2021 4:06 pm
creator wrote: Fri Sep 17, 2021 12:50 pm I've talked to the health insurance company and they confirmed that everything is as per the policy. The only remedy I have is to file an appeal with them.
Sounds like yet another case of buyer's remorse. Did you choose a less expensive (premium) plan and now want relief for your balance due? What don't you understand about "...everything is as per the policy"? Your out of pocket is your out of pocket. Pay it and move on.

And no, $1000 for an ultrasound at a hospital is not out of the question, especially in 2021. I paid 2/3 of that at a hospital over 10 years ago. (Of course I learned then DO NOT GO TO HOSPITAL FOR NON-EMERGENCY ULTRASOUND.)
Last edited by creator on Sat Sep 18, 2021 12:25 pm, edited 1 time in total.
Topic Author
creator
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Re: Hospital Bill Nonsense [Appealing a hospital bill]

Post by creator »

This is a self funded company policy, I believe United HealthCare is just an administrator of this plan. Maybe this is why it is written in such a strange way.
Luckywon wrote: Sat Sep 18, 2021 11:48 am
creator wrote: Sat Sep 18, 2021 11:46 am It is PPO through United HealthCare. I called them yesterday and they confirmed that procedures that are done during ER visit are fully covered by the plan and I will only need to pay $200 copy.
Luckywon wrote: Fri Sep 17, 2021 9:06 pm
creator wrote: Fri Sep 17, 2021 4:04 pm Good point. I will need to confirm this with my health insurance company. Yes, we have a $200 ER copy on the insurance and previously this is only what we paid. My daughter MRI done in ER and we didn't get a separate bill.
I am getting from your posts that you believe getting your ultrasound through the ER would have been cheaper because you would only be responsible for the ER fee of $200 and that would include an ultrasound if needed. And that your experience previously was that your daughter had an MRI through the ER that was included in the ER fee with no additional charges. This scenario is totally alien to my experience and understanding, and I'm a health care worker. Would you mind sharing what your insurance company is? Is this a PPO plan? HMO? Is this Kaiser?
I'm astonished. You learn something new every day. Thank you for clarifying that.
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creator
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Re: Hospital Bill Nonsense [Appealing a hospital bill]

Post by creator »

The basis for an appeal are simple. I avoided ER visit trying to limit cost for myself and insurance without realizing that I will end up paying 5 times more. I am only responsible for $200 copay during ER visit (deductible and co-insurance will not apply). This was confirmed with the insurance yesterday.

The plan is self funded by the company I work for and UHC is just an administrator. I hope company representative will be involved in the decision making and they consider the logic behind it and fairness. If UHC will only utilize the policy to make the decision it is a lost cause.

Again, this is a question of principle for me.
UALflyer wrote: Fri Sep 17, 2021 8:17 pm
creator wrote: Fri Sep 17, 2021 12:50 pmI didn't go to ER ($200 fee) to make it cheaper as it didn't even cross my mind that ultrasound from a hospital will not count as a specialist visit.
Visiting an outpatient facility for an imaging test never, ever counts as a specialist visit.
I've talked to the health insurance company and they confirmed that everything is as per the policy. The only remedy I have is to file an appeal with them. Basically avoiding ER (higher cost to insurance) generated higher costs to me.

I am in a position to pay the bill, but this is a question of principle. I do plan to file an appeal and would appreciate if you have any suggestions on what should be included. I am also outraged that a 15 minutes ultrasound non ER visit costs $1000+. I do understand that hospital has tons of expenses but isn't it a ripoff?
What's the basis for an appeal? Avoiding the ER may or may not have caused your out of pocket cost to be higher, but an appeal based on this basis will fail. Likewise, an argument that an outpatient imaging test should be considered a specialist visit will fail, as will an argument that a 15 minute test should result in a lower cost.

All that is adjudicated during a medical appeal is whether the claim was processed in accordance with your summary of benefits. In order words, in order to be successful, you need to reference specific mistakes, if any, associated with your claim in the specific context of your summary of benefits (the 100+ page long insurance contract that you have). The decision will also reference specific sections of your summary of benefits.
UALflyer
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Re: Hospital Bill Nonsense [Appealing a hospital bill]

Post by UALflyer »

creator wrote: Sat Sep 18, 2021 12:37 pm The basis for an appeal are simple. I avoided ER visit trying to limit cost for myself and insurance without realizing that I will end up paying 5 times more. I am only responsible for $200 copay during ER visit (deductible and co-insurance will not apply). This was confirmed with the insurance yesterday.

The plan is self funded by the company I work for and UHC is just an administrator. I hope company representative will be involved in the decision making and they consider the logic behind it and fairness. If UHC will only utilize the policy to make the decision it is a lost cause.

Again, this is a question of principle for me.
I get what you're saying, but as I mentioned above, this is simply not how medical appeals work. The whole "I could've done X, which would've been cheaper for me, but would've cost you $Y; instead, I did Z, which cost you 10% of $Y. Therefore, I want you to give me the benefit that I would've realized by doing X" is prohibited under the insurance contracts and applicable regulations.

You are certainly free to file an appeal on this basis, but the argument is a loser. I get that you're confused by the health insurance contracts, and are in good company, as plenty of people out there are in the same boat, but there's a reason that people have given you the suggestions above, which do actually have a chance of working. For future reference, an outpatient imaging test is never, ever treated as a "specialist visit," as the CPT codes are completely different. Likewise, the fact that your chosen course of treatment has saved the company money never has anything to do with your medical appeal. The same is true for the amount of time an imaging test or a procedure takes (certain heart surgeries take less time than the time that it can take to set a compound fracture, but the latter is obviously 1,000 times cheaper than the former).

CPT stands for Current Procedural Terminology, and CPT codes is what dictates how reimbursements are processed; for a lot of procedures, CPT codes can be complex, and coding is one of the most common reasons for reimbursement issues. Hence, the reason that people have mentioned that you should look at the codes used. It's not a bad suggestion, but because of their complexity, it is typically incredibly difficult for a non-expert to look at the CPT codes and to come up with a meaningful argument about them in the context of your insurance contract.
Last edited by UALflyer on Sat Sep 18, 2021 1:59 pm, edited 2 times in total.
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LilyFleur
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Re: Hospital Bill Nonsense [Appealing a hospital bill]

Post by LilyFleur »

That is a really interesting insurance policy--a $200 co-pay for an ER visit, and presumably a fairly high deductible otherwise, for non-ER related hospital visits?
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gobel
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Re: Hospital Bill Nonsense [Appealing a hospital bill]

Post by gobel »

LilyFleur wrote: Sat Sep 18, 2021 1:03 pm That is a really interesting insurance policy--a $200 co-pay for an ER visit, and presumably a fairly high deductible otherwise, for non-ER related hospital visits?
Yeah, I always thought this was a surcharge *on top of* all the other medical and facility charges. Maybe OP just has a much better plan than I did.
Mr. Rumples
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Re: Hospital Bill Nonsense [Appealing a hospital bill]

Post by Mr. Rumples »

Since you are appealing and this is a self funded policy, perhaps your company has an ombudsman to reach out to and talk about the issues before the formal appeal? You may not be the only person under your plan who has gone through this. From my personal experience, a back end push sometimes helps.

Even if it doesn't get you anywhere, the ombudsman may be able to advise you that they know this is an issue that has to be addressed - or that they don't care.
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JPM
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Re: Hospital Bill Nonsense [Appealing a hospital bill]

Post by JPM »

For those who would like to avoid such costly financial contretemps when dealing with the health care system and the related health insurance system, google "8 tips for reading your health insurance policy" and after educating yourself on that site, read your insurance policy in light of what you learned there. That will save you from making costly mistaken assumptions about when, where, and whether your policy covers your healthcare expenses. If you do not understand the policy after reading "8 tips" and the policy, then contact HR, your insurance agent, or your insurance company to clarify that which is unclear to you. Clarifying confusion about the insurance policy's terms and coverage is their job and not the job of the service provider.

It is the doctor, lab, or hospital's job to get the coding and billing right and if they don't, it's their job to correct it. A numeric or alphanumeric service code describes the service rendered. As with accounting, what may be a correct coding categorization for an item of service is not always clear and differences of opinion may arise. In general, a service code determines the charge corresponding to the service provider's charge list, and the contract between the insurer and the service provider determines the pay rate or discount rate for the service described by its respective code. The service code is linked to an alphanumeric diagnosis code. The service must be appropriate to the diagnosis to be eligible for coverage.

Insurance companies have internal dispute resolution systems and your state and federal government have external dispute resolution systems when the internal systems fail to resolve an issue or do not apply.
Broken Man 1999
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Re: Hospital Bill Nonsense [Appealing a hospital bill]

Post by Broken Man 1999 »

LilyFleur wrote: Sat Sep 18, 2021 1:03 pm That is a really interesting insurance policy--a $200 co-pay for an ER visit, and presumably a fairly high deductible otherwise, for non-ER related hospital visits?
My MA PPO plan is self-funded by MegaCorp. Some employers (mine included) have really great plans for their retirees and active employees. Of course as a retiree, my health insurance isn't protected, and can be withdrawn at any time. Each fall I open my benefits statement expecting the letter to say MegaCorp is no longer providing me free health insurance. Well, we do pay the Part B premium, lowest tier. So far so good.

For a ER visit, the co-pay is $65, waived if I am admitted. I have never gone to the ER and not been admitted.

For Urgent Care visit, the co-pay is $25. I've never gone to an Urgent Care Center, as I'd rather call my PCP, and get an appointment or go to the ER if he advises me to do so.

We have no deductible for pharmacy or medical, only a max OOP of $3,000. At the moment I have $2,916.17 left to meet my $3,000.00 individual maximum OOP.

I do think the companies who self-fund their insurance have more flexibility for assisting their employees than someone holding a policy of their own.
Strength in numbers and all that.

Broken Man 1999
Last edited by Broken Man 1999 on Sat Sep 18, 2021 4:24 pm, edited 1 time in total.
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Re: Hospital Bill Nonsense [Appealing a hospital bill]

Post by sport »

Broken Man 1999 wrote: Sat Sep 18, 2021 4:23 pm For a ER visit, the co-pay is $65, waived if I am admitted. I have never gone to the ER and not been admitted.
Some years ago, I went to emergency room with potentially serious symptoms. They ran a lot of tests and kept me over night for more tests. However they did not admit me. They were expensive tests. My only cost was the ER copay. If I had been admitted, I would have had Medicare Part B charges with deductibles and co-insurance. So, in my case, it was better not to be admitted.

Being admitted or not is a strange situation.
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Re: Hospital Bill Nonsense [Appealing a hospital bill]

Post by UALflyer »

LilyFleur wrote: Sat Sep 18, 2021 1:03 pm That is a really interesting insurance policy--a $200 co-pay for an ER visit, and presumably a fairly high deductible otherwise, for non-ER related hospital visits?
Unless the OP has a truly weird policy, something is getting lost in translation here. If non-emergent outpatient imaging is subject to a deductible plus a copay, it'd be quite bizarre to have a situation where the ER visits aren't subject to the same deductible and only incur a relatively small flat copay.

What could be the case is that the policy has a provision similar to those founds in some federal health insurance policies out there, where accidental injuries are covered at 100% without a deductible for the first 72 hours. If the OP has a provision like that in his policy, however, and we are talking about an accidental injury, then the coverage typically applies to all forms of treatment and not just the ER (meaning that it'd be covered the same regardless of whether the imaging is done in an outpatient imaging center or in the ER).
Last edited by UALflyer on Sat Sep 18, 2021 6:07 pm, edited 1 time in total.
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LilyFleur
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Re: Hospital Bill Nonsense [Appealing a hospital bill]

Post by LilyFleur »

Broken Man 1999 wrote: Sat Sep 18, 2021 4:23 pm
LilyFleur wrote: Sat Sep 18, 2021 1:03 pm That is a really interesting insurance policy--a $200 co-pay for an ER visit, and presumably a fairly high deductible otherwise, for non-ER related hospital visits?
My MA PPO plan is self-funded by MegaCorp. Some employers (mine included) have really great plans for their retirees and active employees. Of course as a retiree, my health insurance isn't protected, and can be withdrawn at any time. Each fall I open my benefits statement expecting the letter to say MegaCorp is no longer providing me free health insurance. Well, we do pay the Part B premium, lowest tier. So far so good.

For a ER visit, the co-pay is $65, waived if I am admitted. I have never gone to the ER and not been admitted.

For Urgent Care visit, the co-pay is $25. I've never gone to an Urgent Care Center, as I'd rather call my PCP, and get an appointment or go to the ER if he advises me to do so.

We have no deductible for pharmacy or medical, only a max OOP of $3,000. At the moment I have $2,916.17 left to meet my $3,000.00 individual maximum OOP.

I do think the companies who self-fund their insurance have more flexibility for assisting their employees than someone holding a policy of their own.
Strength in numbers and all that.

Broken Man 1999
Wow, that is amazing coverage. My megacorp provides no health care benefits, although companies that got bought by my megacorp negotiated generous retiree healthcare for their employees. So three of my friends who worked there have great retiree health insurance, and I do not. I work part-time just to pay for my health insurance bill and co-pays. Luck of the draw.
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Re: Hospital Bill Nonsense [Appealing a hospital bill]

Post by TropikThunder »

creator wrote: Sat Sep 18, 2021 11:46 am It is PPO through United HealthCare. I called them yesterday and they confirmed that procedures that are done during ER visit are fully covered by the plan and I will only need to pay $200 copy.
There’s no way your insurer can guarantee that’s all you’d have to pay at the ED. Most hospital ED’s are staffed by independent physician groups that don’t work for the hospital. They don’t have to accept the same insurance that the hospital does, and even if they accept the same plans, they may have negotiated different reimbursement schedules. The procedure may well have been covered but you would likely have received provider charges instead, there’s no way for us to tell.
fortunefavored
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Re: Hospital Bill Nonsense [Appealing a hospital bill]

Post by fortunefavored »

UALflyer wrote: Sat Sep 18, 2021 5:42 pm
LilyFleur wrote: Sat Sep 18, 2021 1:03 pm That is a really interesting insurance policy--a $200 co-pay for an ER visit, and presumably a fairly high deductible otherwise, for non-ER related hospital visits?
Unless the OP has a truly weird policy, something is getting lost in translation here. If non-emergent outpatient imaging is subject to a deductible plus a copay, it'd be quite bizarre to have a situation where the ER visits aren't subject to the same deductible and only incur a relatively small flat copays.

What could be the case is that the policy has a provision similar to those founds in some federal health insurance policies out there, where accidental injuries are covered at 100% without a deductible for the first 72 hours. If the OP has a provision like that in his policy, however, and we are talking about an accidental injury, then the coverage typically applies to all forms of treatment and not just the ER (meaning that it'd be covered the same regardless of whether the imaging is done in an outpatient imaging center or in the ER).
This makes perfect sense to me - the $200 copay is the mandatory "ER out of area coverage" required by ACA. Anything else (the urgent care visit) is billed out like normal ($1000.) I also expect they won't change anything, since it is a feature, not a bug.

It's just a quirk of the ACA law. They can bill him for anything EXCEPT an ER visit for a true emergency.

And yes, it sounds insane.. but that is par for the course dealing with the medical industry.
Broken Man 1999
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Re: Hospital Bill Nonsense [Appealing a hospital bill]

Post by Broken Man 1999 »

LilyFleur wrote: Sat Sep 18, 2021 5:56 pm
Broken Man 1999 wrote: Sat Sep 18, 2021 4:23 pm
LilyFleur wrote: Sat Sep 18, 2021 1:03 pm That is a really interesting insurance policy--a $200 co-pay for an ER visit, and presumably a fairly high deductible otherwise, for non-ER related hospital visits?
My MA PPO plan is self-funded by MegaCorp. Some employers (mine included) have really great plans for their retirees and active employees. Of course as a retiree, my health insurance isn't protected, and can be withdrawn at any time. Each fall I open my benefits statement expecting the letter to say MegaCorp is no longer providing me free health insurance. Well, we do pay the Part B premium, lowest tier. So far so good.

For a ER visit, the co-pay is $65, waived if I am admitted. I have never gone to the ER and not been admitted.

For Urgent Care visit, the co-pay is $25. I've never gone to an Urgent Care Center, as I'd rather call my PCP, and get an appointment or go to the ER if he advises me to do so.

We have no deductible for pharmacy or medical, only a max OOP of $3,000. At the moment I have $2,916.17 left to meet my $3,000.00 individual maximum OOP.

I do think the companies who self-fund their insurance have more flexibility for assisting their employees than someone holding a policy of their own.
Strength in numbers and all that.

Broken Man 1999
Wow, that is amazing coverage. My megacorp provides no health care benefits, although companies that got bought by my megacorp negotiated generous retiree healthcare for their employees. So three of my friends who worked there have great retiree health insurance, and I do not. I work part-time just to pay for my health insurance bill and co-pays. Luck of the draw.
Yeah! I survived a bunch of downsizings/rightsizing/RIFs, and for all the stress MegaCorp did right by me and my peers. Currently management has no pension or retiree insurance. We had pension, 401k plan, stock options, and decent health insurance.

It's hard to race to the bottom in product pricing without cutting a lot of expenses along the way. Not pretty for a lot of workers today.

Broken Man 1999
“If I cannot drink Bourbon and smoke cigars in Heaven then I shall not go." - Mark Twain
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LilyFleur
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Re: Hospital Bill Nonsense [Appealing a hospital bill]

Post by LilyFleur »

Broken Man 1999 wrote: Sat Sep 18, 2021 6:07 pm
LilyFleur wrote: Sat Sep 18, 2021 5:56 pm
Broken Man 1999 wrote: Sat Sep 18, 2021 4:23 pm
LilyFleur wrote: Sat Sep 18, 2021 1:03 pm That is a really interesting insurance policy--a $200 co-pay for an ER visit, and presumably a fairly high deductible otherwise, for non-ER related hospital visits?
My MA PPO plan is self-funded by MegaCorp. Some employers (mine included) have really great plans for their retirees and active employees. Of course as a retiree, my health insurance isn't protected, and can be withdrawn at any time. Each fall I open my benefits statement expecting the letter to say MegaCorp is no longer providing me free health insurance. Well, we do pay the Part B premium, lowest tier. So far so good.

For a ER visit, the co-pay is $65, waived if I am admitted. I have never gone to the ER and not been admitted.

For Urgent Care visit, the co-pay is $25. I've never gone to an Urgent Care Center, as I'd rather call my PCP, and get an appointment or go to the ER if he advises me to do so.

We have no deductible for pharmacy or medical, only a max OOP of $3,000. At the moment I have $2,916.17 left to meet my $3,000.00 individual maximum OOP.

I do think the companies who self-fund their insurance have more flexibility for assisting their employees than someone holding a policy of their own.
Strength in numbers and all that.

Broken Man 1999
Wow, that is amazing coverage. My megacorp provides no health care benefits, although companies that got bought by my megacorp negotiated generous retiree healthcare for their employees. So three of my friends who worked there have great retiree health insurance, and I do not. I work part-time just to pay for my health insurance bill and co-pays. Luck of the draw.
Yeah! I survived a bunch of downsizings/rightsizing/RIFs, and for all the stress MegaCorp did right by me and my peers. Currently management has no pension or retiree insurance. We had pension, 401k plan, stock options, and decent health insurance.

It's hard to race to the bottom in product pricing without cutting a lot of expenses along the way. Not pretty for a lot of workers today.

Broken Man 1999
At almost age 62, with an expensive chronic health condition, I am very grateful that I can buy health insurance on the open market, even at a high cost, and I'm grateful for a part-time job to pay for it. Thankfully I am self employed and can take the health insurance premiums as an above-the-line business expense. I run it both ways in Turbotax. Last year, I itemized, because for itemizing, I can include my co-pays as part of the medical expenses. For a business expense, only the premiums are allowed as an above-the-line deduction.
toofache32
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Re: Hospital Bill Nonsense [Appealing a hospital bill]

Post by toofache32 »

creator wrote: Fri Sep 17, 2021 3:51 pm
Artful Dodger wrote: Fri Sep 17, 2021 2:36 pm Different ultrasounds will cost different amounts, but I recently had one and the total cost was $906. I'm on Medicare now, and the allowed amount was $103. So, I'd definitely check to make sure your PPO has repriced the bill before paying anything. I know Medicare will usually get a better deal, so you may not be getting a 88% discount. You may have had a more extensive test, and it could have had a much higher starting bill, but I would confirm first.
Yes, the insurance repriced it to in-network rate. It literally took 15 minutes for a test...
I'm sure they can take longer next time if you ask.

I haven't read all the responses but I'm still looking for evidence that something was billed outside of the insurance agreement you signed. What is there to appeal when you agreed to this financial arrangement?
bgvg
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Re: Hospital Bill Nonsense [Appealing a hospital bill]

Post by bgvg »

I think this podcast episode on negotiating medical bills and researching prices was interesting and it might help:
https://slate.com/podcasts/how-to/2021/ ... dical-care

They seem to cover almost all points mentioned in various news advice articles I've read over the past several years with the exception of letting the bill go to collections and negotiating with the debt collection agency which will hurt your credit score and history. Debt collection agencies buy the debt for pennies on the dollar. There's even a non-profit that buys out $100 worth of debt for just $1 on average.

I haven't read the book - Never Pay the First Bill - yet by the author that was interviewed in the podcast episode, but it may be worth considering:
https://www.amazon.com/gp/product/0593190009
TheDDC
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Re: Hospital Bill Nonsense [Appealing a hospital bill]

Post by TheDDC »

What is your deductible amount per year since this is in network? That would be the max you're responsible for as per the terms of your insurance. With my insurance that ER copay is applied to the bill.

-TheDDC
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Luckywon
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Re: Hospital Bill Nonsense [Appealing a hospital bill]

Post by Luckywon »

TheDDC wrote: Sat Sep 18, 2021 11:44 pm What is your deductible amount per year since this is in network? That would be the max you're responsible for as per the terms of your insurance. With my insurance that ER copay is applied to the bill.

-TheDDC
It appears to me you are confusing the deductible with the maximum out of pocket for in network providers?
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