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.
Do not ever go to an ER if there is an alternative has been my advice for a long time.
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I’m not sure about most group insurance companies, but my medical insurance pays better if I go to an ER rather than one of those emergency clinics.
Any ER doc or and someone else on call could have stitched that up, then you use Vitamin E to take care of the scarring. But NO, you had to have a plastic surgeon to do that. WELL Baby you pay it, you wanted it.
The "usual and customary" fee for the test was let's say $750. The Insurance negotiated rate is $500, which was paid.
The testing facility is coming after me for the remaining $250. That's wrong. They negotiated the rates with the insurance company and I've met my max out of pocket deductible.
Up to this year, my understanding has always been once I've met my max out of pocket deductible, I'm "done." The negotiated rates between the insurnace plan and the doctors that accept those insurance plans are what they get paid (minus any deductible I have left, which is $0.) There's something going on here that I'm not quite understanding, and typically I'm not a dumb guy. I don't think this is right.
The numbers I used above aren't the real numbers (those are significantly higher ..) and not knowing what I'll have to pay to repair the AC Joint in my left shoulder (it's completely separated and painful to reach across my chest or push from any direction) means I'm not going to do it until I know what it's going to cost.
“.) There’s something going on here that I’m not quite understanding, and typically I’m not a dumb guy”
“Insurance” (investment) Lobby = Congress, Mitch Nancy and the RICO.
“I can’t even get a straight answer if the anesthesiologist and recovery room staff are on hospital staff or paid contractors (which my insurance won’t cover.)”
At least for the anesthesiologist, they should have a list of those who are under contract with the hospital. But, overall, maybe call BCBS, I have them too, and I remember being told not to worry, as long as I use an in-network hospital.
4 years ago I shredded my finger in an electric hedge trimmer. The doc in a box sent me to the ER. X-ray and 10 stitches was $2,000. A month later I was sent another $230 bill for a “Doctor’s fee”.
Another example of why we should learn to code.
Just becuase you use an in-network hospital doesn't mean the anesthesiologist, recovery room nurses & staff, etc.. are also in-network.
That bit me in the ass when I had to have wrist surgery to re-attach my right wrist back to my arm with two titanium plates and 12 screws. $8k worth of bit me in the ass.
What happened to the good old days? My youngest son was born in the early 90s and I had the standard work provided health care where I paid $200 a month for a then family of three.
Younger son’s birth including all prenatal visits and an overnight in the hospital was around $300.
I accidentally stabbed myself in the wrist back in July. Deep wound about 1/2 inch long that would have taken at least 3 stitches. Cleaned it out with peroxide and sealed it up with super glue. There is a nice scar but it healed up just fine.
ROFL! You forgot the cold beer!
I use a .32 hilti gun with purple charges and four prong three inch beam fasteners for all my medical stitching. They stay stitched and don’t come back.
When I had some surgery the list price was $24k, with the negotiated payment of $8k including my $2000 copay, so the the hospital only had a 3x factor for that vs. 20x for the tests. Looking at my lifetime of medical bills, I got far more value from the difference between the MSRP and negotiated rate than I got from the amount the insurance company actually paid. My ideal insurance would be lower payments per month to get the negotiated rate plus payments for catastrophic bills and they wouldn't pay anything most years like car insurance.
wrong type of coding.. sorry
by coding i meant diagnosis coding, huge books just filled with the proper code that needs to be used for payment of services
100% to everything you said especially about benefitting from the negotiated rate.
Maybe it’s a good analogy maybe not but it’s a bit like paying to join a “buyers club” as opposed to a straightforward indemnity.
The dirty secret is that the “MSRP” can often be whatever the billing entity says it is. In many cases (some cases) it can border on a scam which you escape if you get the negotiated rate.
Two things. Deductibles max out for a given uear. Copays may (if you really have a max out of pocket provision) but also may not (if you don’t).
You EOB (Explanation of Benefits) from your insurance company is the “source of truth”.
If it says you don’t owe an in network provider anything but they are still coming after you then you’re on very solid ground in fighting it.
I was trying to be funny, dammit. :)
LOL, i knew you were :-)
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