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Medical claim denial question

2,283 Views | 14 Replies | Last: 4 yr ago by The Wonderer
Beckdiesel03
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I am dealing with a claim that was denied by my insurance for an ER trip back in December. Basically my plan renewed and what I didn't know was that illness wont be covered the first 5 days of my plan, and yep, got extremely ill on day 3 of new plan and it was denied.
My question is this- dealing with all of the bills I have received I am currently trying to negotiate them down and get them paid. They of coarse tried to bill me huge amounts, because of the denial, but at the same time, my insurance has sent me an EOB for all of them with their contracted amount which is about 1/3 of the price they are trying to bill me for. So since I was insured with them, do the have to honor that amount, or since insurance isnt covering illness can they tell me to pound sand?
thank you for any help or advice
AgPT06
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If you can. Offer them a one time payment at or below the contracted rate. If they wont gove you that tell them you want a payment plan. Pay the absolute minimum. In 6 to 9 months they will likely settle.
Ducks4brkfast
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So your company went through it's annual renewal and left you uninsured for 5 days?
dubi
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Ducks4brkfast said:

So your company went through it's annual renewal and left you uninsured for 5 days?
That sucks!

Carrier switch?
ATM9000
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AgPT06 said:

If you can. Offer them a one time payment at or below the contracted rate. If they wont gove you that tell them you want a payment plan. Pay the absolute minimum. In 6 to 9 months they will likely settle.


What do you mean by 'pay the absolute minimum'?

I think you are giving horrible advice based on how people think medical debt works, but want to make sure you are saying what I think you are.
Beckdiesel03
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Due to not having health insurance through work we have been using golden rule by United for the last several years and their short term policies after years of problems with Obamacare policies. They recently switched to where the first five days of your policy your not covered for illness yet they won't approve your new application for renewal with an overlap of dates. So yea it sucks and I wasn't aware of that. I was able to eventually get on my work plan but now I'm just trying to get this cleaned up and paid without being ridiculously overcharged and ruining my credit. The kicker is they said the claim went into review but then never bothered to inform anyone of the outcome of it. I had to call last week and see what was going on with the review status.
AgPT06
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I have had a similar situation. I too have used short term policies and share programs and have had the fun of doing the hospital negotiations dance. When I say "pay the minimum", I mean the minimum monthly that they agree to. Something that is in writing and will not get the debt sent to collections. For example we had a $8k hospital bill due to lack of coverage. They agreed to us to pay $2000 up front and put remaining $6000 at $250/month. We paid that for about 6 months and then they called us (end of year) and asked if we could settle the account. I still $4500. I said I could pay $2500 and they took that and closed the account. This was with the Christus hospital system.
Beckdiesel03
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Mine is also with Christus and so far the actual hospital seems to be the easiest to work with. The actual ER doctor bill and that business have NOT.
ATM9000
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AgPT06 said:

I have had a similar situation. I too have used short term policies and share programs and have had the fun of doing the hospital negotiations dance. When I say "pay the minimum", I mean the minimum monthly that they agree to. Something that is in writing and will not get the debt sent to collections. For example we had a $8k hospital bill due to lack of coverage. They agreed to us to pay $2000 up front and put remaining $6000 at $250/month. We paid that for about 6 months and then they called us (end of year) and asked if we could settle the account. I still $4500. I said I could pay $2500 and they took that and closed the account. This was with the Christus hospital system.


Got it and fair enough. My understanding of medical debt though is this:

1. Generally there's nothing special about medical debt despite popular belief. Doctors and hospitals just generally won't ever report unpaid debt to credit agencies.

2. Even if you are sending minimum payments to a hospital or doctor, if doctors need cash, they are going to discount your debt to a 'collections agency'. At that point, they still can't report your debt to credit agencies unless you miss a payment. But just know your medical debt is just unsecured debt just like a delinquent credit card... and the debt gets reset to month 1 every time your make a payment on the 7 year clock.

I'm not calling the minimum payment strategy a bad one, but it isn't without risks. If the medical provider gets tired of taking your low payment monthly and wants cash, for example and sells the debt to a creditor and you don't pay your bill on time, they are probably reporting that debt faster than you can imagine.
P.H. Dexippus
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I deal with medical bills frequently although I am not in the healthcare industry. Your typical medical provider has a "rack" or "charge master" rate for services that starts as a negotiation point. When you have insurance in place, there is a pre-negotiated discount rate for a given procedure/care/equipment (usually 1/3-1/5 rack), and an understanding that some charges may be written off altogether.

If you don't have insurance, often times you can negotiate a cash rate up front. Knowing the typical rack rate mark up % can be helpful here. Likewise, uninsured medical can usually be negotiated down to 1/3-1/5 of rack rate. Get it in writing that you are offering lump sum for a full release of the charges and that the debt hasn't been sold to a third party (this is not intended as legal advice and I am not your lawyer).
Beckdiesel03
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Thank you everyone for all of the helpful responses. After dreading this for so many months and finally knowing the claim review was denied, I forced myself to start calling the hospital and ER doc today yet again and get it worked out. The hospital knocked their bill down to almost nothing and I finally got a rep from the doctor that told me what the self pay discount would be (75% !!) which no other rep in the past had told me was even an option. So needless to say this is getting taken care of for about 1/5 of price I thought it would be originally and even after talking to them several times. Thank you all very much
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dubi
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SoupNazi2001 said:

This thread provides a glimpse into everything that is wrong with our healthcare system. Hospital and doctors bill a huge amount but will take huge discounts if paid. The whole contracted insurance rates is such a scam as well. Why don't they just charge everyone the contracted rates and not some obscene number.

So they can provide that huge made up FIGURES to the govt when they provide care to the uninsured.

OH WAIT, ISN'T EVERYONE SUPPOSED TO BE INSURED?
shihitemuslim
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Is your insurance a fully funded or self funded policy. Call your insurance and ask. You got different ways of dealing with the claim depending on if it's fully funded or self funded. If you find out I instruct you on what to do.
Beckdiesel03
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Don't even get me started on the entire healthcare system bc my family has had to deal with Obamacare and that entire scam since the beginning. I've posted on numerous threads over the years as to all the crap that we have had to deal with. My sons eye specialist is the only doc we see that has a true cash price and that's bc he is used to people paying to see him outside their insurance. His fees are cheaper than me paying "cash" for a dental cleaning...smh
The Wonderer
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I handle these types of issues after years of being an in-house counsel with medical providers and hospitals and working with medical billing companies. I'm always happy to answer questions.

cody@dumaslawpllc.com
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