Well, hopefully they know more about medical diagnosis and treatment than you do. 
Well, DH was bleeding all over the floor and he still had to sign with his other hand that he knew he would be responsible for the out of network charges if such a doc treated him. It was in a sentence in all the ER admitting forms. Just wrong.
Sometimes a patient will ask that the doctor use a different diagnosis because the appropriate diagnosis for the condition is not covered by their insurance or for that procedure, but another diagnosis (which is not the appropriate diagnosis) is. This can put the doctor at risk for fraudulent billing. Companies should take these issues up with the almighty insurance companies, not let it fall to the patient to ask their doctor to potentially engage in fraudulent billing.
Singersmom07,
You will probably have success if you do what thumper did- contact your insurance company and tell them this was an emergency and you were seen in the nearest ER.
Many years ago DS#1 broke his leg when skiing. He had to be transported from local dippy hospital to the nearest one where the orthopedist could perform surgery. First the insu co tried to charge us for one of the ambulance rides, failing to understand that it was not a duplicate charge, and then charged us the OON rate for the second hospital because it was out of network. Many many phonecalls later I finally got a wonderful claims rep who not only fixed the denial of the second ambulance trip but spontaneously informed me that because they transferred him to the closest hospital where he could be treated, the situation was considered an emergency (it was) and the policy is to cover all such situations as in network. She reprocessed all the claims and we got a very nice refund. And she actually followed up and called back when she promised. Very refreshing. I still remember her name. I wrote a very nice letter to her supervisor both as a customer and provider for that insurance company, that apparently went all the way up the chain to the top brass both within her office and in the benefits office of DH’s company, and was apparently posted on every bulletin board in her claims office. She was my new best friend and helped me with many billing and insurance issues (when DH broke his ankle out of state she handled the billing/claims submission for the purchase we made at a medical supply place, etc) Unfortunately for me, my letter got her promoted and I lost her assistance.
Are all forms electronic now? If you’re in an in-network emergency room and the forms say you agree to pay for out-of-network providers, couldn’t you just cross that off a paper form and sign it? I remember doing that many years ago when I took my 2-year-old to the ER. She had pneumonia that the doctor I’d taken her to the day before didn’t catch and her temperature spiked in the middle of the night. Whatever the clause was that I didn’t like, the staff let it go and I never heard anymore about it.
If the forms are electronic, can’t you get a paper copy? Or refuse to sign altogether? I thought ERs were required to treat people. It’s unethical to essentially blackmail them into signing whatever the hospital wants by denying treatment if they refuse to agree to the hospital’s terms.
The hospitalist who oversaw my inpatient care when I had the heart attack was out of network. She works exclusively under contract at the in-network hospital where I was taken. I had no choice of practitioners. Insurance and provider refused to budge.
The cardiologist who put in my five stents the night I had a full cardiac arrest and a 100% LAD blockage was paid $1200 (billed $7000). The procedure took three hours longer than standard, was an extremely complicated procedure, and I had already been defibrillated several times. The hospital notes documented all this stuff and I have a copy of the records from that time. 46 pages of harrowing reading. Insurance company ignored the exigencies.
My oncologist’s lab consistently misprocessed my PCR test for leukemia. Got lots of $1200 bills for quarterly testing that was supposed to cost me $33. Trashed my credit rating for a while as I fought the billing office. At long last, the lab decided not to accept my insurance company any longer, so I am now stuck with LabCorp. OTOH, the tests have been coded correctly ever since.
Many years ago, a young child had a nasty bacterial infection. They had Kaiser insurance. Kaiser made them drive past several closer ERs to the hospital they contracted with, losing precious time. Ultimately the child lost several limbs. The monstrously large house that the attorney who represented the family lives in is known as “the house that Kaiser built”. Kaiser subsequently changed their policy for emergencies and ERs.
Re the provider billing the patient a percentage of a full fee vs. a percentage of the secret agreed-upon fee (#50-55 up thread) – That was exactly what happened when D was born 25 years ago. The insurer was supposed to pay 90%, I was supposed to pay 10%, but it turned out that secret pricing in effect meant that I was paying a much larger percentage of the bill than I was supposed to pay. Dug this out after trying to reconcile charges and payments with a secondary insurer. Ended up lead plaintiff in a class action lawsuit which cost the insurer a whole lot more than it would have cost if they’d simply have refunded me when I asked nicely the first two times. (So, if the approved amount was $10,000, I was supposed to pay $1,000, and the insurance company was supposed to pay the doc $9,000. However, there were confidential payment rates behind the published approved amounts that reduced the insurance company’ actual payment to, say, $8,000 – even though the explanation of benefits they sent to me said they’d paid $9,000.
With insurance companies, I trust nothing. Verify everything. Know your appeal rights, and use them dotting all the i’s and crossing all the t’s.
Insurance companies are scum. Absolutely. But have not seen balance billing issues or padded copays in a while. Doesn’t mean it might not happen, but your EOB should be pretty transparent. It looks and sounds like they purposely fraudulently put the wrong payment amount on your EOB, and is was inconsistent with what was sent to the secondary insurer. They should get what they deserve for that. That’s disgusting.
Jym626, DH had a cut across his hand that went almost to the bone, bleeding a lot and definitely in pain. He did not read the entire thing until he was told about it by the doctors billing office on a follow up visit. I was not there and our son took him.
That’s unacceptable, Singersmom. I’d still complain to the Insurance company and if necessary to the insurance commissioners office if they screw you. It was an EMERGENCY. What does your policy say about coverage for an OON doc in an emergency?? Check your company’s policy on line if you can, or talk to your HR department (NOT benefits-- benefits doesn’t care. HR should). Or an ombudsman.
This is the first time I have heard that any insurance companies allowed this. Most would just pay the lower charge and disallow the more expensive one. With Medicare it would trigger a fraud investigation. This forces the healthcare providers to give away a lot of free services.
One thing that affects my wife’s clinic is that the independent clinics have no negotiating leverage at all, even as members of the state alliance of independent clinics. Insurance payments are “take it or leave it” and decreasing every year. Insurance companies pay out, on average, 50% more for each person who receives health care through a hospital organization. Some states are trying to address this, though most are not, including Washington. Our state “Medical Committee” is chaired by a person strongly allied with the insurance companies.
Also, it is illegal to use a medical code other than what was actually performed, so using an eye injection code for eye drops is against the law despite it being common practice and almost never pursued. It’s an issue with cash pay people when she doesn’t want to charge so much for something expensive, but it can’t be in the chart unless it is coded and would not be covered by malpractice insurance unless it is in the chart.
My wife spends hours every week fighting with insurance companies on behalf of her patients. Most primary care providers have given up and will no longer do this.
All the stories of the smarmy stuff the insurance companies do to screw the providers and the customers reminded me of when UHC did this to OON providers. They created this side company called Ingenix, who used wrong data (they found the lowest billing rates they could find in the areas) to artificially lower the UCRs (usual and customary rates) so they would underpay the docs based on these artificially low #s and then the patient would pay an artificially high copay. They got their butts sued by NY state and California and paid millions and millions. Probably a drop in the bucket to them http://www.amednews.com/article/20090126/business/301269997/1/
@simba9 - Did you work for that billing software company around the time that @arabrab discovered that the insurance companies were lying on their EOBs and claiming they paid more to the docs than they did? That’s disgusting and the insurance company doing that should have been shut down for that massive fraud and possible collusion. Somehow makes me think of the banking bailouts-- in that how could we let these institutions fail…
I think I need to wash my hands. Feels slimy just typing the words.
I’m surprised that the person mentioned upthread who was so helpful with a claim got promoted. I bet many insurance companies would fire someone who actually paid a claim!
They probably moved her out of claims processing! A colleague of mine had a client who had developed anxiety- he worked for an insurance company and was rewarded for stalling on or denying claims. The longer they kept $ in their account or didn’t have to pay out because the patients gave up appealing, the happier the insurance companies were.
I’m still trying to get paid for a claim from an OON provider from September. Provider completed billing with ICD-( and 10 coding as her professional listserve recommended), and it was kicked for having both codes. Said we needed to use ICD-10 and would not process with both codes on the form. That kicked. Now trying it with ICD-9 only.
Same thing happened with a bill from my primary doc, also OON. In both cases, I have to pay the full bill up front and then get reimbursed, so it’s my money the insurance company is sitting on. That 25% OON copay is never, ever 25%.
Insurance companies surely have algorithms that estimate how many people will give up and pay on a claim vs. who will fight, and figure that into their profit margin. Don’t mess with me and my money!
I have Anthem blue cross blue shield. Went to the gyn who recommended an ultrasound and extensive labwork. $1000 bill for labs for which I have to pay $65. Ultrasound was $500 for which I’m billed $272. I find it cheaper to go to cvs minute clinic instead of going to the doctor.
CD-
IIRC, bills for services before Oct 1 should have had the ICD-9 code, even if the bill wasn’t sent until After Oct 1. ITs for the DOS, not the day the bill was generated.
I fought, both as a provider and as a parent of a kid whose insurance screwed up, for 2 years, to get claims processed correctly. I’m with you-- they don’t know who they are messing with. I caught them in several lies and my attorney sent a letter (on son’s claim) alluding to their engaging in discrimination. Finally, after 2 years of persistence, those claims were paid, and my patients claims were paid (2 different insurers, Same lies, stalling, claim that they didn’t get appeals sent certified/return receipt , which I had) etc. I asked for a Dr to Dr review on my son’s situation, since it happened to be in my area of specialization, and they had to admit a dr had not really looked ad the submitted materials, despite their claim to the contrary. Had to get HR involved, and my patients had to get their HR departments involved. Had internal contacts at one of the company. It still took 2 years of BS, denials (on preauthorized services!) appeals, etc. I got the claims paid. Finally.
Yes, @jym626, she was probably promoted “up and out” so they could save face while moving the person who was actually paying claims.