Posted on 10/28/2021 4:30:55 PM PDT by nickcarraway
— Despite impending regulations, surprise billing still happens
One day in March 2020, during the height of the pandemic, Melinda Wenner Moyer's daughter, Jojo, fell off her bike in the driveway and cut her forehead on a rock.
After a quick consult with their primary care doctor, who said the 5-year-old needed stitches, and a trip to a nearby urgent care, which didn't think they could do the procedure without scarring, the mother and daughter set out for the emergency department. It was a 40-minute drive away, in Westchester, New York.
They went to the Maria Fareri Children's Hospital's emergency room. Moyer requested an on-call plastic surgeon, because someone had advised her to do so in a situation that called for stitches.
When the doctor, Anthony Alessi, DMD, MD, came in after a wait, the visit was quick: "He just stitched up her forehead, it took like, five minutes," Moyer said. "And then -- now I have this bill."
Moyer got Alessi's bill -- which listed a Los Angeles P.O. Box rather than a New York office -- a year and a half after the visit.
It totaled $21,500 -- $17,000 for the procedure, and $4,500 for the emergency department visit.
"THIS ACCOUNT IS SERIOUSLY PAST DUE, PLEASE CONTACT OUR OFFICE IMMEDIATELY," a note on the bill read.
Moyer was shocked: "I was not expecting that this morning."
After all, she thought, her insurance, UnitedHealthcare, covers ED visits, as they had in the past. When they left that day with 10 stitches in Jojo's forehead, "I didn't think about it at all. I assumed it was 100% covered."
But it wasn't that simple. Emergency physicians or doctors on call often aren't employed directly by the hospital. They can be contractors who are out-of-network for a patient's insurance, even if the hospital is in-network. The doctors or the staffing agencies that employ them negotiate with insurance companies for payment, while hospitals can send insurers separate bills for their part of the work.
In this case, Alessi had submitted a claim to UnitedHealthcare four times, according to Explanation of Benefits statements that Moyer shared with MedPage Today. Those claims were rejected by the insurance company all four times for what they said was "an incorrect or inappropriate primary diagnosis code."
Failing to get payment from the Moyers' insurance, Alessi's office passed the bill on to the Moyers themselves -- a practice known as "surprise billing."
Regulators have tried to address these bills, passing state and federal legislation that's supposed to protect patients from enormous charges for emergency services. The federal No Surprises Act gives patients a way out of the bills, while insurers and providers, if they cannot agree on payment, go through an independent resolution process.
New York State law also allows New Yorkers to be "protected from surprise bills when treated by a non-participating (out-of-network) doctor at a participating hospital or ambulatory surgical center in their health plan's network" using a similar process.
It's not clear if the New York state law applies to the Moyers' employee-issued insurance plan, and because federal laws haven't taken effect yet, the Moyers may still end up with a big bill.
On Wednesday, Moyer called UnitedHealthcare to ask whether she was indeed responsible for the sum. The claims representative explained that Alessi's office still needed to provide additional information, but that the insurer would continue to process the claim.
"This $21,500 is actually not your responsibility," a UnitedHealthcare representative told Moyer.
From the bill, however, it appeared that it was. Moyer herself is a science journalist, and even for someone who knows the healthcare field better than most, the charge was still mystifying.
"How do people who do not have any background in ... healthcare or health ... manage this and navigate this?" she said. "It's so hard."
The insurer said Alessi's office needed to re-submit the bill with different codes. As the codes stood, they would duplicate claims that were already paid out. The hospital had asked for $683 and UnitedHealthcare had paid $267.
UnitedHealthcare said they had communicated the problem to Alessi's office and they were still waiting to hear back.
A billing representative for Alessi's office said they had submitted a claim to UnitedHealthcare and hadn't heard that they needed to resubmit different information.
When asked why they sent the bill, Alessi's representative said the "purpose is to send her a statement so she can confirm she had received this service with this doctor, and she can call her insurance carrier, and then we can go from there."
The representative said she needed to leave a paper trail for the negotiation to move forward. It wouldn't have worked, she said, to explain this to Moyer.
"If I called her and said 'this is the balance in full,' she might think 'okay, this is a scam,'" the representative told MedPage Today.
Instead, the bill arrived with the overdue notice.
"Clearly that was a bill and they were hoping I would pay it," Moyer said.
The UnitedHealthcare claims representative acknowledged to Moyer that Alessi is indeed an out-of-network provider who would "have the right to pass the bill to you guys, since you are the patient, and they don't have a contract with United Healthcare."
UnitedHealthcare said it would wait for the claim to be re-submitted correctly, and then negotiate with the physician: "Whatever amount they agree upon, then that's the amount that we are going to cover," the UnitedHealthcare representative told Moyer.
But depending on what the negotiated amount is, the Moyers may find themselves once again hit with a huge bill.
About he same for a Cat or Dog at the Vet for “emergency surgery”.
It is all way out of hand...
Baseball arbitration (leaving the victims out) is needed for out of network billing. The medical provider would propose what they think is a fair billing and the insurer would propose what they think is a fair payment. The arbitrator would decide which was the closest to fair, and the insurer would pay that amount. The victim would be liable only for in=network level copays and deductables. That would get the out of network billings down to reasonable levels in a hurry.
When I was a kid and needed stitches, my grandma would sew me up. I think she almost enjoyed it. Granted, it’s okay for boys to have a scare or two. Little girls on the other hand, no so much. But those were some expensive stitches.
She demanded the on-call plastic surgeon. When you specify top shelf rather than house swill, you’re going to pay.
When I was a flight attendant, I got a sinus infection and couldn’t fly. Even though I sounded like death warmed over, my supervisor required me to get a doctor’s note. I had to take my dog to the vet and asked him to write me a note excusing me from work and he did. He added a charge to my dog’s bill but it was cheaper than my copay.
I knew a guy owned the er corp at a local hospital.
I also know how the hospital billing tax writeoff scam works.
Do not ever go to an ER if there is an alternative has been my advice for a long time.
I watched my one friend stitch the other friend.
There might have been alcohol involved...
Yea, a trail of paper $100 bills!
Yeah--my dad performed the stitches on me as well.
But he was a surgeon.
I noticed that as well.
When you specify top shelf rather than house swill, you’re going to pay.
What an eye opener for the entitled brat (mom, not the kid).
This important piece of information is, of course, buried deep in the article. But as long as there's a sensationalistic headline to grab clicks, the goal has been met.
Yup. I’ve only been in one once or twice and it was a scam every time.
If urgent care can’t fix it and I can’t do anything with pliers, I’m just gonna have to live with it.
Pfft. Took my kid to the ER when he was 4. Knew he needed stitches because I could see the adipose tissue poking out.
Sewed him up in a jiffy. Does he have a scar? Yes. Will it teach him to not run with scissors in sock feet on a hardwood floor after I told him NUMEROUS times not to? You betcha.
And there's the problem.
Duct tape is sufficient for adult males.
a needle and thread, and a tube of superglue are also good optional items to consider in addition to pliers
The plastic surgeon is up coding for a few stitches on a child, United will keep denying for incorrect coding, Dr’s billing service needs to fix and payment will be issued. And ya mom screwed up the er Dr would have done it for way less.
worried about scars? requested a plastic surgeon? what does she expect?
Disclaimer: Opinions posted on Free Republic are those of the individual posters and do not necessarily represent the opinion of Free Republic or its management. All materials posted herein are protected by copyright law and the exemption for fair use of copyrighted works.