Financial situation...help, please!

[BakersDozen]

Our babies were in the NICU for one month. Every visit from the doctor was covered almost 100% (thank goodness as every visit was $916!) except for one weekend when a Dr. Patel was doing rounds; his visit was charged full price because he was out-of-network. I was not informed of his network status and am now facing a hefty bill that we cannot afford to pay. I have challenged these charges given the fact that we were in a hospital that was in-network and had every single doctor/procedure covered as in-network. The fact that the physician's group brought an out-of-network doctor in without informing me was, imo, completely unfair. What really gets me is that one month after we left Dr. Patel was brought into the group and is now in-network!

 

I received a letter today stating that my challenge has been considered and denied; I owe almost $3000 and I want to cry. I cannot believe how unfair this is.

 

Please, ladies, is there anything else I can possibly do? I don't know how they think they will get this money from us. Right now we can pay about $10/month which is a far cry from the $100/month payment they are demanding.

 

I'm a mess. We have tried so hard over the years to be financially responsible, we refused to let taxpayers foot the bills for our choices in life, we set aside $ for the twin pregnancy/delivery and were able to pay for everything else yet this out-of-network charge came out of nowhere and I am MAD!

[Mama Lynx]

Is there someone higher up you can appeal to? I had a similar charge - the in-network doc used an out-of-network lab. I appealed, and we got it covered. They really should do the same for you. Can you appeal again, or appeal the appeal?

[Little Nyssa]

:grouphug: Can you meet with the head doctor of the group, who must know you from your NICU time and might be able to intervene? This seems completely unreasonable.

[dragons in the flower bed]

Sometimes a local news agency will pick this sort of thing up as a human interest story and hassle the insurance company on your behalf.

[Iucounu]

Talk to an attorney. Depending on the state and specific facts, you may have a decent insurance claim and/or consumer protection claim, and the attorney will likely be able to tell you about your chances of defeating the matter if they sue for collection.

[T'smom]

Ugh. I feel your pain. I was just telling a friend yesterday about a remarkably similar experience that we had. The newborn hearing test people were "out of network". I made phone calls and wrote letters and it was all denied. They didn't care that we hadn't been given a choice of providers and since everything else at that hospital was covered. Ugh. If I were you I'd argue as many times as possible. Maybe calling up that particular doctors office (instead of the ins.) might at least get you a discount or something. Maybe you could work out payment directly with them and maybe they'll let you pay $10/month.

[Anne in CA]

Definitely do not drop it, and bring the doctor himself in if necessary and ask that he waive the fees. I would start making personal calls on people to make sure that they are uncomfortable saying no to your face. I do think you can get it fixed, it will probably just take time and persistence. You will probably have to put as much time in as if it were a part time job, but I'm sure it can be done. I have had similar situations and worked them out, but I had to consider it a job and work at it a little every day.

[starwarsmomma]

Go to the hospital, doctor, AND insurance company and dispute the charge, IN WRITING. Nag them to death, disputing the charge, and be nice but naggy.

 

I have a child who is frequently in the hospital, and have to do this often. Sometimes it takes up to a year of phone calls, disputes, and emails/letters. Just don't stop, keep pestering.

 

They are just hoping you won't dispute and will pay the bill.

[VinNY]

Call your State Attorney General's Office. Ask for advice and their help. Write a letter to your doctor's group informing then that you are going to pursue this with the Attorney General's office etc. because they did not inform you of going out of network. See what happens.

[melissel]

Ugh, I am so sorry. Every time I see that disclaimer sign in the hospital about this, I get outraged all over again. I think it should be illegal--it's practically a bait-and-switch. I have a bunch of hospital-related stuff coming up and I'm so paranoid about this happening without my knowledge!

 

:grouphug::grouphug::grouphug: I feel your pain. I would be devastated.

[BakersDozen]

Thank you all for the suggestions. I'll do everything I possibly can starting today.

[Guest]

Be persistent. I bet they figure you'll just pay up. Tell them it's their fault and that you should have been notified if the doctor was out of network. Keep going higher and higher up.

[melissad2]

Call your State Attorney General's Office. Ask for advice and their help. Write a letter to your doctor's group informing then that you are going to pursue this with the Attorney General's office etc. because they did not inform you of going out of network. See what happens.

 

:iagree:

 

In fact, I had to do just that when my son was born with a heart defect and sent to the NICU and then flown to a children's hospital. The insurance company denied ALL of his claims because they said we needed "preapproval" for the services he received:confused:. OK...we didn't expect him to be born with a heart defect and sort of had other things on our mind in the midst of it all!

 

They eventually paid everything but our deductible.

[Unicorn.]

I agree w/ all of the pps' advice. Contact an attorney, the attorney general, and your insurance company in writing, and don't give up! Also, be aware that they will pressure you to pay $100 month, but as long as you are paying $5 or $10 a month, they can't do anything about it. They will threaten collections agencies and even if they do turn it over, just ignore the calls from the collection agency, and continue to pay the small monthly amt. It aslo won't affect your credit-they don't look at medical.

Great big :grouphug:! BTDT. Don't let it stress you!

[Oak Knoll Mom]

Call your State Attorney General's Office.

 

:iagree: or your state's Insurance Commissioner. My cousin had a similar situation where she had insurance on herself through her employer, but her baby was going to be on her DH's insurance when she was born. My cousin's insurance wanted her to give birth at hospital A, but the baby's insurance said they would only pay for the baby's expenses if she was born at hospital B. The state insurance commissioner finally got involved and it all worked out, but my cousin had to make a lot of calls and pester the right people before the baby's insurance would pay.

[kitten18]

Call your State Attorney General's Office. Ask for advice and their help. Write a letter to your doctor's group informing then that you are going to pursue this with the Attorney General's office etc. because they did not inform you of going out of network. See what happens.

This is where I would start also.

[StephanieZ]

Don't cave. This is abusive. Dispute the charges, in writing, to everyone in the chain (doctor, hospital, insurance, etc). Update and reprint your dispute letters once a month & keep mailing them. I agree with the idea of making a nominal payment monthly, but not to exceed the total balance you expect to owe.

 

I can't vouch for the payment failure preventing it from hurting your credit, as I've never been in that situation. So, if protecting your credit is vital (upcoming mortgage, etc), you might need to be proactive about protecting your credit, too. I do know that many SMALL businesses will avoid reporting delinquincy if you are making regular payments, even if they are very modest payments. Total failure to make a payment will usually result in it getting turned over to collections quickly.

 

I also agree with complaining to your state's insurance regulators, atty general, etc. This stuff is so horrible.

 

Have hope & keep trying! We recently had our dental insurance company play hard ball on a bill for me. It was for the replacement of an entirely BROKEN crown (that was over a decade old). It was a no-brainer necessity and clearly covered. The insurance covered crowns, and had done so many times in the past. Anyway, we'd actually changed insurers soon after the work was done, and the insurance company decided to deny the claim. They did the exact same denial for a different procedure for another staff member. They'd been great about claims the entire 5 years we'd had them up until these last months of coverage.

 

Anyway, it took us about 10 months, and at least 5 phone calls and forms, and several from the dentist's office, and redoing things multiple times . . . but they finally paid the claim. It was obvious that they were just waiting us out, trying to outlast our patience. We won. :) (FWIW, we DID pay the dentist out of pocket after 6 months, and then kept fighting with the insurance for reimbursement, as we didn't want the dentist to suffer for OUR insurance problems.)

[VinNY]

This is what I recommend.

 

We had a situation in the ER. My husband had an accident with his hand..long story short, after three hours in the ER, and a PA working on my husband's hand the head ER dr called him off and then arranged to call in a specialist w/o our OK. (They were backed up). By the time the specialist saw my husband's hand it was too swollen to be taken care of (needed a pin and surgery) so he stitched it up and arranged for us to have follow-up surgery in a week.

 

The bill for this specialist was over $6,000 for 45 minutes. Insurance covered $345. With the encouragement of many including a dear DR. friend, we called and wrote the President of the hospital, the head ER doctor and then the State's Attny General's office. It took two months, but we only paid $200 to this specialist ..case closed where no one admits fault.

 

Persistence and indignation worked to our advantage. You have a sympathetic case, document it and state repeatedly that you were proactive about who and what your insurance covered and arranged accordingly. The medical field needs to understand that they can not decide to spend your money w/o your consent.

[lynn]

BTDT. I hope you get the right people to talk to that can help get this issue resolved.

Edited February 15, 2012 by lynn

[J-rap]

I would fight it to the bitter end! I think you have a strong case. Bring in an attorney, if necessary. Or threaten to.

[theYoungerMrsWarde]

:grouphug: When we were with the Catholic Mercy hospital they had financial assistance available, and a patron/donations paid for the part we were responsible, but would have taken us years to pay off. But when ds2 had surgery at US Davis, they only had financial assistance for people without insurance. We still have (I think) 2 years to go, to pay for a surgery that happened when he was 9 months old (and that was with our very good insurance.) Are you with the kind of hospital that has the good kind of financial assistance?

 

I have a lot of respect for you for not wanting to have tax payers cover the money; we are the same way. And I commend you for being responsible and saving ahead of time for the twins.

[justamouse]

Don't pay it, be the squeaky wheel and call the State Attny General.

 

We had a few charges like that come up and we refused to pay. They ended up paying it the end, but you ahve to MAKE them.

 

Whatever you do, don't pay it now and expect to get reimbursed.

[Joanne]

Follow up diligently. But also know that you don't have to take their calls.

 

They can not reposses your babies. It is HIGHLY unlikely they'll sue you and garnish your wages. Keep sending them what you can (if the fight is over).

[TammyinTN]

Fight it...there's no way that should of happened.

[Cara in Ky]

You have gotten some good advice on here. I would also add that you need to keep a written log. Write down the name, job title, and direct phone line of everyone you talk/write to along with the date, time and what was discussed.

[momto3innc]

We had a similar situation when my middle son needed emergency surgery. Hospital was in network, referring physician was in network, surgeon was not. We were denied multiple times. My husband was persistent, annoying, and thorough. He kept meticulous records of everything, talked to everyone, read through the nitty gritty of insurance codes, etc... Finally fully paid minus our copay 10 months later. Ugly but finally fixed. He is much tougher than me so he did the calls.

[Susan C.]

1. Appeal again

2. Contact your State Board of Insurance, they are the agency that licenses insurance companies to do business in your state. They will help you!

 

We had this happen several times, with one, only needed one appeal to get it resolved. They try to wear you down so you will pay. Not one penny until you do #1 and #2!! They can't do anything to you while negotiating with the insurance company. This happens to us pretty close to every hospitalization, one went over a year and everybody waited. I called every doctor/hospital once a month to check in. Insurance companies ALL eventually paid.

[Brilliant]

If you haven't already, I suggest you read over your policy documents with a fine-tooth comb. (you might find these online if you don't have a copy). I was charged for a non-network pathologist at an in-network hospital where I had surgery last year. My policy had a section under covered network charges that said certain specialist services at an in-network hospital would always be charged at an in-network rate. I printed a copy of that page and sent it along with the appeal form and the explanation of benefits. The insurer adjusted it within days.

 

Good luck to you with this.

[TKDmom]

I had a similar thing happen when my ds was in PICU. Only one of the doctors in the practice was on my insurance, but another one visited at least once. The doctor's office actually resubmitted the claim under his (the in-network doctor's) name so that they could be reimbursed by my insurance company. This was done before they ever sent me a bill, and I was glad not to be stuck with the $400/visit just because a different doctor was on call.

 

I'd call the the doctor's office, explain the situation to them, and see if they'd be willing to resubmit the claim under another doctor's name, since you cannot afford to pay their bill without insurance.

Edited February 16, 2012 by bonniebeth4
clarification

[LMA]

Our babies were in the NICU for one month. Every visit from the doctor was covered almost 100% (thank goodness as every visit was $916!) except for one weekend when a Dr. Patel was doing rounds; his visit was charged full price because he was out-of-network. I was not informed of his network status and am now facing a hefty bill that we cannot afford to pay. I have challenged these charges given the fact that we were in a hospital that was in-network and had every single doctor/procedure covered as in-network. The fact that the physician's group brought an out-of-network doctor in without informing me was, imo, completely unfair. What really gets me is that one month after we left Dr. Patel was brought into the group and is now in-network!

 

I received a letter today stating that my challenge has been considered and denied; I owe almost $3000 and I want to cry. I cannot believe how unfair this is.

 

Please, ladies, is there anything else I can possibly do? I don't know how they think they will get this money from us. Right now we can pay about $10/month which is a far cry from the $100/month payment they are demanding.

 

I'm a mess. We have tried so hard over the years to be financially responsible, we refused to let taxpayers foot the bills for our choices in life, we set aside $ for the twin pregnancy/delivery and were able to pay for everything else yet this out-of-network charge came out of nowhere and I am MAD!

 

Who did you challenge and from whom did the letter come? Is this your insurance company or the hospital or the doctor's office?

[G5052]

I've been doing this sort of thing for over a decade. I've met with office managers, sent letters to the doctor, and challenged the insurance company. The key is to show that you care about getting the bill resolved and to pay some on it even if the final amount is still in question. Thankfully we've never had one that was unsurmountable, although it took time to work out the final amount and then pay it off.

 

The reality is that if you have complex medical problems, you likely will enounter things that are out-of-network.

[laundrycrisis]

When this happened to us - an in-network hospital called in an out-of-network specialist for our son who was an admitted patient without getting required clearance first - I refused to pay the bill. I just told them no, and spelled out that this was their fault and that they would only be getting what our insurance would pay and what our portion would have been for an in-network doctor and nothing more. They screwed up by calling in a doctor who was not in our network although they were a network hospital. I called the doctor's practice and told them this and sent a letter. I called the hospital and told them this and sent them a letter as well. Somehow my letter made it to their "patient advocacy" department, and the charges in excess of what our insurance would cover and what our in-network portion would have been were waived. We received a much reduced bill.

[Amy in NH]

I refused to pay the bill. I just told them no, and spelled out that this was their fault and that they would only be getting what our insurance would pay and what our portion would have been for an in-network doctor and nothing more.

 

:iagree:

 

Or you can appeal it again. My mother, who worked for health insurance companies as a claims reviewer, says that some companies will pay on the third appeal. or not. I wouldn't pay it, though.

 

I had a similar situation in which my in-network PCP sent my routine bloodwork to an out-of-network lab to the tune of $450 not covered by insurance. I refused to pay. I did not go to that lab to have my blood drawn; it was drawn in the doctors office. I did not request that they send it to that lab for processing; it was an error on the part of my doctor's office. I told the lab to take it up with them. When the lab sent the bill to collections I told the collections agency that I was appealing it; they made note of it and stopped sending me bills.

[BakersDozen]

Who did you challenge and from whom did the letter come? Is this your insurance company or the hospital or the doctor's office?

I challenged the physician's group directly and addressed my letter to the patient care coordinator. I have not called to see if there is someone above her to whom I can address another appeal. I began this appeal process last month with my insurance company which told me to take the issue up with the doctor's office.

[BlsdMama]

No advice, just ((hugs))

 

Don't let the worry steal your joy over these tiny and precious miracles mama! :)

[Cindyg]

I'm pretty sure that in some states what happened to you is not legal. There is no way a patient (who might be unconscious) can verify that everyone who touches her body or her labwork is in network.

 

Google the term "In Network Hosptial" "Out of Network Doctor" Disputes

 

You'll get many hits. Start with this article: http://shine.yahoo.com/vitality/9-secrets-health-insurers-dont-want-you-to-know-2467416.html

 

Please do speak with an attorney, even if it's some sort of free ask-an-attorney website. And please post back and let us know what you learn.

 

What happened to you is horrible, and it could happen to any of us.

Edited February 16, 2012 by Cindyg

[Liz CA]

Same thing happened to me. Don't fret over it. Keep challenging it. Write a letter to the doc's office explaining that you never asked him to see you/your kids and that you cannot pay anyone who is an out of network provider.

 

My situation was that an assistant surgeon whom I had never met prior to surgery and was not informed that she would be present, sent me a bill.

She was not in the network. Her accountant called me and I told him point blank that I had never met this doctor, had never asked her to assist, was never informed by my surgeon (whom I knew, of course) that she would be assisting. Therefore I would not pay anything.

I then wrote a letter detailing this very scenario on paper. They wrote it off.

[Liz CA]

Exactly. See my post below.

[Janie Grace]

Be persistent. I bet they figure you'll just pay up. Tell them it's their fault and that you should have been notified if the doctor was out of network. Keep going higher and higher up.

 

:iagree: You absolutely should not have to pay that bill.

[laundrycrisis]

I challenged the physician's group directly and addressed my letter to the patient care coordinator. I have not called to see if there is someone above her to whom I can address another appeal. I began this appeal process last month with my insurance company which told me to take the issue up with the doctor's office.

 

I would not expect your insurance to cover it. I would expect the doctor's practice to write off most of it. You may ask your insurance company to help you figure out what your cost would have been if he was in network, and then you can agree to pay that amount (but don't pay it yet). Also the hospital may discuss the case with the doctor's practice. That is what happened with mine. The hospital asked the practice to write it off.

[inmyopinion]

Go to the hospital, doctor, AND insurance company and dispute the charge, IN WRITING. Nag them to death, disputing the charge, and be nice but naggy.

 

I have a child who is frequently in the hospital, and have to do this often. Sometimes it takes up to a year of phone calls, disputes, and emails/letters. Just don't stop, keep pestering.

 

They are just hoping you won't dispute and will pay the bill.

 

Also, check with your employer. We had a similar thing happen with us and we told the head of benefits. Since the company was self insured, he ended up overriding the denial and told them to pay it. Even if the company is not self insured having the "customer" call may get stuff moving.

Most denials are automatic so keep fighting it.

Sorry that you have to deal with this on top of eveything else.

[JFSinIL]

What state are you in, and what insurance co?

 

Hubby handles this sort of thing all the time and I want to run it by him.no promises.

 

Here is his website:

http://www.stepnowskilaw.com/BalanceBilling.html

 

he thinks most other states may have similar laws but he needs to know where you are to look it up.

Edited February 16, 2012 by JFSinIL

[JFSinIL]

http://shine.yahoo.com/vitality/9-secrets-health-insurers-dont-want-you-to-know-2467416.html

 

he left the above window open on the computer, too - so I am posting it.

[LMA]

I challenged the physician's group directly and addressed my letter to the patient care coordinator. I have not called to see if there is someone above her to whom I can address another appeal. I began this appeal process last month with my insurance company which told me to take the issue up with the doctor's office.

 

This has happened to us. You are doing the process correctly. CC your insurance company and the doctor's group and the hospital's financial office on all of your letters. Send your letters certified. You don't have control over in-network and out-of-network when in the hospital. It will take a while.

[Twilight Woods]

you need to contact the physicians group ask to speak with the top Dr there.

[SweetPea]

I haven't read all the other posts, so this may have been covered already. Anyway, my first dc was born at a in-network hospital and he was checked over by a dr who turned out to be out-of-network. Now, this dr. was the "hospital's" peditirician of the day and not who we listed.

 

I brought my protest up with my insurance company. They did end up dropping our out-of-network charges. Reason: I had my baby at a preapproved in-network hospital. I could not "card" every doctor that needed to check my premie dc....not possible....and I was at the correct hospital.

 

Make sure to log all your calls to the insurance company - name/date/time/subject. It took persistence, but after calling weekly over a month it was fixed. Keep repeating yourself - network hospital , network hospital.

[BakersDozen]

What state are you in, and what insurance co?

 

Hubby handles this sort of thing all the time and I want to run it by him.no promises.

 

 

AZ, Blue Cross/Blue Shield with Administrative Enterprises as the blood suckers...er, I mean middle-man. :glare: Thank you (and your dh) in advance for any help you can give!

[Dawn E]

I would not expect your insurance to cover it. I would expect the doctor's practice to write off most of it. You may ask your insurance company to help you figure out what your cost would have been if he was in network, and then you can agree to pay that amount (but don't pay it yet). Also the hospital may discuss the case with the doctor's practice.

 

:iagree:

[Paige]

I would not expect your insurance to cover it. I would expect the doctor's practice to write off most of it. You may ask your insurance company to help you figure out what your cost would have been if he was in network, and then you can agree to pay that amount (but don't pay it yet). Also the hospital may discuss the case with the doctor's practice. That is what happened with mine. The hospital asked the practice to write it off.

I agree.

 

I had a similar issue resolved just a few weeks ago. It was the hospital's fault for not getting the physician credentialed before allowing him to see patients. The fact that they did get him signed up with your insurance later shows that they were aware of the necessity. They should write it off. I would talk to someone in the customer service/billing department at the hospital and appeal to them. Your insurance probably won't be any help because it isn't their fault. Our issue was taken care of with a phone call to the right person but if that doesn't work, dispute it in writing and do not pay. We made the mistake of paying for the hospital's error once and we will never see that money again! Your insurance won't pay you back for something you never should have paid and good luck getting it from the hospital. When you get a bill, call the billing and remind them that you are not paying because you are appealing the charges. This should flag your account and keep it from going to collections. Even if it goes to collections, it doesn't make it your responsibility. You are still disputing it. You can call the credit reporting bureau and dispute the collections on your account.

[Susan C.]

Call the person in charge of patient relations at the hospital for help, I call it patient advocate, but every hospital has someone, they are just called different names. It would be the person that came to see you while you were in the hospital and gave you their card so you could call if you had any concerns.