tiomasai
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Arriba Arriba!
Posts: 246
Queens, NY,
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Diane:
There is so much I could tell you about health insurance that I've experienced in the last 10 years that would make anyone on this board cringe.
Technically, yes, if you are out of network, the hospital can bill you what insurance does not consider UC - usual and customary. They can also bill you for anything the insurance company doesn't consider covered, whether or IN or OUT of network.
The numbers are ridiculous. I will never understand why a hospital can bill a patient with in network insurance a $1000 procedure only to be paid $50, and then bill the same procedure to someone else with out of network insurance, get paid $50 and then bill the remaining to the patient. It's the difference between IN and OUT. INSANE!
That being said, there are ways to fight these things. I have so many stories...
When I had my stroke, I sat in the hospital, lucky enough to speak and say, I only wanted doctors in my PPO. I was at the hospital I WORK FOR, NO LESS! Well, someone didn't pay attention, and the doctor who did my angiogram was not in my PPO. My hospital billed me $4000 for the procedure -- that was AFTER the insurance paid them. Well, I fought and fought and fought (while preparing for surgery, no less!).
First they said they would write it off. Then they said they wouldn't. After what seemed a multitude of faxes, they came back and said it was written off. Then you know what they did? THEY fought the insurance company and WON (they said even though the doctor was out of network, the hospital was in network). So it's okay if it's my money, but not okay if it's theirs? The lesson? Make the HOSPITAL fight for it with the INSURANCE company, not YOU.
During my follow up, my MRI didn't get covered. First they said my doctor wasn't covered, then they said it was outside of my precert date. I kept faxing my precert and saying that I was covered. Eventually, the insurance company realized that someone scanned in the WRONG precert (it wasn't even mine, it was someone else's!!, as I had never even heard of the doctor). They fixed it, it got covered. This was after five months and about 8 phone calls.
Billing is not just an insurance company issue. It depends on how the hospitals bill too. I found out the hard way that Columbia and Stanford bill differently. Stanford bills all facility procedures under in network status of the hospital. Columbia bills under in network status of the doctor writing the report. That being said, I took a test at Columbia and got billed $400 that my insurance didn't cover b/c the doctor who wrote the report (who I didn't know, and was NOT my doctor who ordered the test) was not in my PPO. I appealed, saying had I known he was going to write the report, I wouldn't have taken the test. I should have a choice whether or not I'm going to take a test if I am going to be forced to pay for it. This is America, HELLO, what happened to freedom of choice!!
Don't get me wrong. I'm not advocating not taking the test. It's the principle. Most people do not go to the store, pay $400 for a TV they've never seen before, and don't know if it works, without a guarantee that it can be fixed or replaced or can get their money back if there is a problem.
I am a huge advocate of information on billing. When it comes to signing those forms that say you are responsible for anything that insurance does not pay for, I always write under it that I want to be informed of all charges before any procedures are done. ALWAYS. I get a copy of these forms with my writing that on them too. So if the hospital comes back and says, well you signed this form, I reply with, well, you were supposed to tell me how much.
As far as Stanford, I have to tell you that I had a pretty good experience. I got the same thing that Chelsea got (I think it was the same thing?), that the experimental procedure of hypothermic something or other that Dr. Steinberg does with anesthesia is not covered. Stanford wrote it off for me for both, when I called the rep. Most of the reps are good, and those who were not helpful, I asked for supervisors. Just keep going up the chain, and be forceful. If they feel you’re hesitant, they won’t back down. Persistence is also key to wearing them down.
I also think you should try Lore’s route too, if you get nowhere with Stanford. Find out if Stanford is in-network and Dr. Steinberg is out-of-network. That situation is there in a lot of places, and maybe you can argue that if the facility is in-network, so should all the physician billing.
Trust me, I know this is frustrating. 2005 was a year of medical billing for me, and it took me until July 2006 to reconcile everything, and I was lucky enough to pay only the required co-pays.
Oh, and ask for detailed billing from Stanford – it helped me a lot to reconcile what my insurance paid and what Stanford was billing for. The bill they send initially is very basic – if you request it, you’ll get a very detailed bill. Ask for details from both physician and hospital billing (they are separate, with different phone numbers). I got billed for $45 on my second surgery (not covered according to insurance). When I got the detailed bills, I noticed the same thing got covered on my first surgery. After two months of phone calls and faxes, the hospital and I discovered that the first one was billed with the right diagnosis, but the second wasn’t. Once the hospital fixed that, they billed it correctly and it was covered.
I hope this helps. Hang in there, and let me know if I can help with any of your calling or appeal writing. You’ll get it all resolved, I’m sure of it!!
Hugs,
Trina
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