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Surprise Medical Billing

3,792 Views | 37 Replies | Last: 4 yr ago by aggiederelict
Thomas Sowell, PhD
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AG
Seems like try as I may, I always get a bill for some provider the hospital uses that is out-of-network with my BCBS insurance.
What can you do? I'm definitely not paying a dime. I've paid $6,000 and met my in-network out of pocket maximum. I pay the high premiums, the high deductibles, and then max out and then the hospital surprises me with hefty claims denied because they used out-if-network providers. I'm sure somewhere in the 10 pages of contract you sign the hospital lawyers used the right wording to use a loophole and all the verbal asking about "is everything covered in-network?" is for nothing.
Do you need to bring your own attorney and contract to admission?
Bert315
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I can only speak for the facility I work for in Houston but they are supposed to make you aware prior to services that it is out of network. If they are using an out of network specialist then you should be made aware prior to. You should be able to call the hospital customer service to get it worked out. I know the facility I work with does not allow out of network balance billing if a physician wants to use our facilities.

The industry is going through a lot of changes and you are seeing more and more hospitals looking for ways to be able to provide patients with 1 price for all services as a way to prevent these kinds of issues. I think this is coming but obviously will not occur overnight. It needs to happen though.
bigtruckguy3500
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It's a bunch of BS. I understand the advantages of allowing insurers to negotiate prices with different provider groups and hospitals and stuff, but I think it's ridiculous that it's virtually impossible to get a straight answer when you want to know how much something will cost prior to getting it.

It's because of BS like this that we're going to move towards increased regulation and/or single payer.
LOYAL AG
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The irony of a Dr *****ing about medical care billing!

Username definitely does NOT check out!
Thomas Sowell, PhD
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I get the irony. I let my patients know that if we go over the allotted time then that's on me and 95% of the time I go over. I have gone over by 2 hours before and not charged a penny. Typically I go over 25 minutes. I have never surprised anyone with billing.
In this latest incident I was looking like a lunatic asking if the radiologist would also be in-network when I found out a CT scan was going to be done in 5 minutes as an IV is connected to me already. All my specific requests and questions ran off water like a duck's back at the triage area of the ER. Nobody wants to admit to you that "Buddy you're going to get surprised, now would you like lube? Forget all those premiums and deductibles you've paid, that was just the pre-party. It's orgy time."
In my case I had paid the maximum out-of-pocket for BCBS, so how much they billed didn't matter but if an out-of-network person was used I was exposed and all my inquiries and instructions to not have them use out-of-network people fell on deaf ears. As I said, I'm sure that loopholes were there in writing as you read from a screen and sign with an electronic pen unable to make markups on what you're signing. It's a well oiled mechanism that knows how to r_pe you.
jopatura
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If you were at a real, legitimate hospital ER, they have to bill the out of network providers at the in-network rate if the facility is in-network. We run into this a lot and one call to the insurance company that we got a bill usually clears it up. If they don't, you can file an appeal with the Texas Department of Insurance.

If it was a standalone ER, that's a ****ing headache. Just go straight to TDI.
Thomas Sowell, PhD
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My deductible for in-network was met. My out-of-pocket max was met for in-network. If any charge was treated as out-of-network I'm stuck with a bill. I was clear with them to not use out-of-network services but and I didn't bring my own contract, my own lawyers, nor could I mark up anything I may have seen on the electronic notebooks they use for signatures.
The hospital was Memorial Hermann The Woodlands. They said they were in-network as I called them on my way to the ER. I wouldn't have gone there if they hesitated on saying they were in-network.
jopatura
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I get that. What I'm saying is for the hospital to be considered in-network for your insurance, they have to accept all parts of the visit as in-network. If you call your insurance company and tell them you got a surprise bill (I'm assuming from the ER doc itself) they will rerun the claim as in-network.

My youngest has epilepsy so we're in an ER at least twice a year when we have to get stronger meds to calm down a seizure. Every time we get an additional bill for the doctor but insurance takes care of it. The only time they didn't was when I took my husband to a stand-alone ER.
Bert315
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I would call Hermann and cite that you had called to confirm in network. As has been said previously, they should have either notified you of the out of network or billed as in network. Their customer service should be able to help. If not I would file a TDI claim.

Unfortunately Hermann is one of the worst at situations like this. They are non-profit but act like a for profit with how they treat and even sue patients. I am not at Hermann but did work with them in a past job and, based on my experience, would not work for them or go for treatment unless a major culture change occurs.

LOYAL AG
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DrHeadShrink said:

I get the irony. I let my patients know that if we go over the allotted time then that's on me and 95% of the time I go over. I have gone over by 2 hours before and not charged a penny. Typically I go over 25 minutes. I have never surprised anyone with billing.
In this latest incident I was looking like a lunatic asking if the radiologist would also be in-network when I found out a CT scan was going to be done in 5 minutes as an IV is connected to me already. All my specific requests and questions ran off water like a duck's back at the triage area of the ER. Nobody wants to admit to you that "Buddy you're going to get surprised, now would you like lube? Forget all those premiums and deductibles you've paid, that was just the pre-party. It's orgy time."
In my case I had paid the maximum out-of-pocket for BCBS, so how much they billed didn't matter but if an out-of-network person was used I was exposed and all my inquiries and instructions to not have them use out-of-network people fell on deaf ears. As I said, I'm sure that loopholes were there in writing as you read from a screen and sign with an electronic pen unable to make markups on what you're signing. It's a well oiled mechanism that knows how to r_pe you.
Oh I get the frustration. I think unfortunately we've all been there, done that. it's actually more frustrating that it happens to you given that you know the system better than the average Joe. Good luck. Hopefully it all works out.
Vernada
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DrHeadShrink said:

Seems like try as I may, I always get a bill for some provider the hospital uses that is out-of-network with my BCBS insurance.
What can you do? I'm definitely not paying a dime. I've paid $6,000 and met my in-network out of pocket maximum. I pay the high premiums, the high deductibles, and then max out and then the hospital surprises me with hefty claims denied because they used out-if-network providers. I'm sure somewhere in the 10 pages of contract you sign the hospital lawyers used the right wording to use a loophole and all the verbal asking about "is everything covered in-network?" is for nothing.
Do you need to bring your own attorney and contract to admission?


Yes. To keep from getting getting hosed, the only choice is to never need medical care or to take a very specialized attorney with you. Otherwise, you are getting 100% Fd regardless of your insurance situation.

The whole system blows. Everyone knows it blows and just hope they aren't tht ones screwed.
Vernada
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And we all knew 'single payer' is the best solution. But no one will say that. We'll all tolerate getting Fd over and over and over and still claim it's the best way. But for anyone that's ever used the system we all know it's terrible.
chico
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These people might be able to help https://healthadvocatespeakers.com/

LOYAL AG
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Vernada said:

And we all knew 'single payer' is the best solution. But no one will say that. We'll all tolerate getting Fd over and over and over and still claim it's the best way. But for anyone that's ever used the system we all know it's terrible.
WTF? Government has played a huge role in creating this mess and we'll need a complete government takeover to make it right? Is that what you just said?
Vernada
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Obviously you've never had to really use the system. I hope you never do.
Bert315
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Vernada said:

And we all knew 'single payer' is the best solution. But no one will say that. We'll all tolerate getting Fd over and over and over and still claim it's the best way. But for anyone that's ever used the system we all know it's terrible.


As someone who has family that lives in a country that has a single payer system, you ha e no idea what you are talking about. Our system has its flaws but single payer is not the answer. Either way you are going to pay for it.
LOYAL AG
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Vernada said:

Obviously you've never had to really use the system. I hope you never do.


Anyone who's ever lived under a single payer system hopes we never go that route. It's the worst idea there is. Anyone in America thinking more government is ever a good idea should never be taken seriously.
shihitemuslim
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What does you BCBS insurance card say in the front. Does it have the initials TDI on it. What does it read on the back. I'm trying to figure out if you have a self funded or fully funded plan. Makes a big difference as they are governed by different laws.
bigtruckguy3500
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LOYAL AG said:

Vernada said:

Obviously you've never had to really use the system. I hope you never do.


Anyone who's ever lived under a single payer system hopes we never go that route. It's the worst idea there is. Anyone in America thinking more government is ever a good idea should never be taken seriously.
I know tons of people that live, or have lived, in single payer countries, and I hear very few to no complaints.

The problem with us in the US is that we want healthcare and we want it NOW. We don't want to wait two days to see our primary doctor for a sore throat, so we go to the ER and seek the most expensive form of healthcare. We don't want to wait to see our PCP for stomach pain/diarrhea, and then have him possibly send us to GI, we want to be able to go straight to the specialist ourselves. We don't want to wait and see if our kid's snotty nose is just snot, we want to go straight to ENT to see if it's nasal polyps.

If we're willing to accept the fact that we don't need this immediate access to specialists and doctors for 99.99% of issues that befall us, and we're willing to accept that more money and more tests doesn't equate to better healthcare, then we'll do just fine with a system similar to many other countries.

Macpappy99
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jopatura said:

What I'm saying is for the hospital to be considered in-network for your insurance, they have to accept all parts of the visit as in-network. If you call your insurance company and tell them you got a surprise bill (I'm assuming from the ER doc itself) they will rerun the claim as in-network.


Do exactly this. I work in the healthcare revenue cycle and this happens so often because the insurance companies just run the claim through their system and the "rules" are applied incorrectly. I review all my explanation of benefits after er visits and major procedures and i would say i find something that has to be corrected 75% of the time. Usually takes a couple of minutes on the phone with a real person at the insurance company to correct.
bigtruckguy3500
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Sorry for the bump, but worth a listen/read: Boston Hospital Leader: U.S. Health Care Has A Bureaucracy Problem.
ramblin_ag02
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There is a giant war going on to see who will get all the healthcare money. The hospitals, the drug companies, and the insurance companies are all fighting to max out their part of the pie. None of them care about the average patient. I've seen it from the professional side and from the patient side and been screwed both ways. The above poster is right. The whole mess is going to drive America into the arms of purely government healthcare, for better or for worse, because it certainly can't be any worse than this.

As far as single payer, it's a big "meh" from me. The reason other countries have successful single payer systems is the overwhelming prioritization of preventative and primary care. You can do that without a single payer system, but it's not easy. Our system overwhelmingly prioritizes specialist and emergency care. So while in France you have to wait for an MRI due to lack of radiology funding, in America you end up in an ER for a cold due to lack of primary care funding.
No material on this site is intended to be a substitute for professional medical advice, diagnosis or treatment. See full Medical Disclaimer.
Zman91
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jopatura said:

If you were at a real, legitimate hospital ER, they have to bill the out of network providers at the in-network rate if the facility is in-network. We run into this a lot and one call to the insurance company that we got a bill usually clears it up. If they don't, you can file an appeal with the Texas Department of Insurance.

If it was a standalone ER, that's a ****ing headache. Just go straight to TDI.
In 2018 my daughter was hospitalized for pneumonia and had to have a VATS , anytime we received an out of network bill all it took was one phone call to the insurance. We have Aetna and we were told that anytime we received an out of network bill and did not have a choice in the provider used it would be billed at in network. We were pleasantly surprised about how easy it was, btw medical bills totaled a little over $120,000 for 4 days n hospital and surgery. Thank goodness we have good insurance.
Dr. Not Yet Dr. Ag
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Hospitals are not trying to use "loopholes" to make you out of network. They are trying everything they can to make sure you are being billed as in-network so that they can actually collect what they bill for. People who receive "surprise bills" typically don't pay the full bill. Where the issue comes from is individual physicians. Most ER physicians are not hospital employees, and the ER staffing agency that staffs a specific ER usually has not negotiated in-network status with various insurers. So despite showing up to in-network facilities, the ER doctor will frequently be an out-of-network provider, unfortunately. So when the ER physicians staffing agency sends a bill to the insurer, and it is refused, they send the patient the balanced bill (or surprise bill). The funny thing is that then people then blame the physicians or hospitals for being greedy when the real issue is your insurance company creating "networks" as a smokescreen for not wanting to pay for all of your care.

Balanced billing is a major topic of discussion across the country, and numerous states have passed legislation regarding this recently, including Texas a few months ago (link below).

https://www.texastribune.org/2020/01/02/what-you-need-to-know-about-texas-new-surprise-medical-billing-law/
No material on this site is intended to be a substitute for professional medical advice, diagnosis or treatment. See full Medical Disclaimer.
TThom
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Out of curiosity how did this end? I happen to work for the company that staffs the MH Woodlands ED (at a different facility). My understanding is that our corporate policy is not to directly bill the patient in this situation. This is an issue between our company and your insurance.

The whole "suprise billing" is the insurance companies way of constantly reducing their payouts and using a massive misinformation scheme to get shady legislation passed to their benefit.

I'm in no way defending the lack of transparency in our current system in regards to costs. That's a whole other disaster and a different discussion
Vernada
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Quote:

Most ER physicians are not hospital employees,
So this is the problem and you think the user should blame their insurance company?

Sorry, if I've done my homework and go to an in-network facility and get "surprised" billed because they have someone working there who isn't 'in-network', I'm getting mad at the facility... I'm not in charge of, or privy to, your HR staffing decisions.

If you're going to have 3rd parties working for you, then as far as I'm concerned how you (the facility) pays them (the 3rd party ER doc) is none of my business. I expect to pay you (via insurance) the in-network rate.

Just think how ridiculous that sounds from the patient/user standpoint.

Vernada
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Quote:

the ER staffing agency that staffs a specific ER usually has not negotiated in-network status with various insurers.
Why do hospitals not require back-to-back agreements? That seems pretty reasonable - you want the contract to work our ER? Here's the agreements we have that you have to agree to also.
TThom
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Nm choosing not to engage
Vernada
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TThom said:

Nm choosing not to engage
Why not, I'd like to learn more about the behind the scenes... I'm assuming there's some reason for it, and I know frustration with the system is felt on all sides. But I don't think my first reaction is unreasonable.
Dr. Not Yet Dr. Ag
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Vernada said:

Quote:

Most ER physicians are not hospital employees,
So this is the problem and you think the user should blame their insurance company?

Sorry, if I've done my homework and go to an in-network facility and get "surprised" billed because they have someone working there who isn't 'in-network', I'm getting mad at the facility... I'm not in charge of, or privy to, your HR staffing decisions.

If you're going to have 3rd parties working for you, then as far as I'm concerned how you (the facility) pays them (the 3rd party ER doc) is none of my business. I expect to pay you (via insurance) the in-network rate.

Just think how ridiculous that sounds from the patient/user standpoint.


The facility did not create the network, your insurance company did as a ploy to save themselves money. Despite this everyone seems to blame everyone except the creators of this mess. Most physicians you see in a hospital are not staffed by the hospital outside of teaching facilities except for usually the hospitalists, but even they are frequently not staffed by the hospital. These independent groups typically attempt to contract with insurance company to become in-network providers where there is a fully negotiated reimbursement; however, because most of these smaller independent physician groups have minimal negotiating power with insurance companies, they get low-balled, so the independent groups refuse to contract with them.

Again, the insurance companies knows all of this, and knows that you have no choice in the case of an emergency and takes advantage of this by creating networks in order to refuse pay for emergent services. In fact most insurance companies have been narrowing their networks as a cost savings solution. It is not the hospital's or the physician's fault that your insurance company is refusing to pay, that choice was made entirely by your insurance company.
No material on this site is intended to be a substitute for professional medical advice, diagnosis or treatment. See full Medical Disclaimer.
bigtruckguy3500
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Vernada said:

Quote:

Most ER physicians are not hospital employees,

If you're going to have 3rd parties working for you, then as far as I'm concerned how you (the facility) pays them (the 3rd party ER doc) is none of my business. I expect to pay you (via insurance) the in-network rate.

If you want to see surprise billing, and a lot of other insurance scams, go away real quick, I propose all patients must file their own insurance claims to get reimbursed for the hospital.

Just stop billing insurance and bill the patient only. Then have the patient submit the bill to insurance. When the hospital has to hire fewer people to fight with insurance companies it'll lower bills. When patients have to go through the headache of claims denied again and again, or only partially reimbursed, we'll very quickly see change happening due to the sheer outrage of what insurance companies can get away with.

Also, the in-network rate varies substantially from entity to entity. A large hospital, especially if it's one of the few options in an area, can negotiate better rates than a smaller one. As such, there's no "insurance can just pay an out of network provider the in network rate." They often don't pay, or if they do, it's pennies compared to what the service was worth.

Seriously, just simplify everything and make everything cash pay. Don't require anyone to have insurance. But for those that do, make them deal with the insurance companies themselves. Imagine how much more of a streamlined process medical billing would be? What you see (before services are rendered) is what you get.
Vernada
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AG
Why does the hospital not employ doctors?
Vernada
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AG
I'd be 100% for this. But it's a waste of breath to even propose or discuss. I don't think anything will ever really change until the system basically breaks... and then it'll take a drastic swing to single payer.

Basically, I don't think you'll ever get all the different parties to come together and push for any reasonable changes.

Everyone knows it's a terrible system. But no one seems to be doing anything to actually make it better. My family is on a CDHP which seems like the most responsible way to 'consume' healthcare. But obviously I'm not moving the needle.

Maybe we need some vocal CEOs to come together and say they are done providing health insurance to their employees?

Until the , Ill just dread the next time I have to really use the system.
Harry Stone
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AG
i had to take my son to the ER last year and i got into it with the staff at Texas Childrens. Be careful what you sign. He had fallen and cut his face near his eye pretty good. i knew we hadnt paid anything on our deductible that year so i knew it would cost, but those ER visits can run up to $10K. I had to talk to admin to make sure they didnt surprise bill me or bring in an OON. they probably hated me but **** them they overcharge anyway and they dont know i work in the health industry so i was prepared for them.
Dr. Not Yet Dr. Ag
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Some do, most doctors however, are either independent contractors or are employees of independent medical groups. I'm sure the trend towards hospital owned practices will eventually carry over to emergency medicine and anesthesiology and other specialties that typically are not hospital employees, but for now that is not the case.

The reason most hospitals don't employ most of the physicians that work there is because they are frequently losing money on their employed physicians and there is a significant amount of administrative burden to employing us. Having to keep up with each physician's CME, licensing requirements, etc. along with recruiting new physicians is a lot of work. It is usually much easier to just contract with a group of physicians and have that group deal with paying the docs, filling out their CME/licensing requirements, and doing their own recruiting.
No material on this site is intended to be a substitute for professional medical advice, diagnosis or treatment. See full Medical Disclaimer.
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