Getting the shaft from health insurance, need advice

[dont slow down]

So back in early December my fiance wasn't feeling good and I ended up taking her to the ER (that's the short story). She has health insurance through Golden Rule and pays about 100$ per month for her coverage since she isn't eligible for it yet through her work or my work till we are married. We recently moved here and set everything up through her insurance which included finding out which hospitals, doctors, etc were in her "Network". I took her to the ER at about 10pm and we went to the closest hospital that was in her network. After they fixed her up we went home. In January we get a bill from the ER for about $8000. Her insurance "negotiated" it down to $1100. We are barely making it as is so she called the hospital and set up a payment plan for $100 per month. In early February we get a bill from the ER doctor for another $1500. We call her insurance about it and they say they never got the bill and for us to have the doctor resend it. They resend it and the insurance company says they won't cover it because the doctor isn't in the network! We told them how can the hospital be in the network and not the doctor?! They say there is nothing they can do and to call the doctors group and negotiate with them. The doctors group won't work with us at all other than a payment plan. We can't afford another monthly doctors bill when it should have been covered by the insurance if you ask me.

So that's it. I don't have any ideas, it's just plain wrong but I don't know what else to do about it. Any ideas?

[Dostradamas]

Pay em or don't.
They don't care.
This sucks.... I feel for you but the system does not care about you or any individual, only getting paid.
Soon the gov will be the provider, at least now you have the legal right to sue the insurance co (waste of time I know,) but you can't sue the gov.

[Jeckler]

We went through the same thing back in August for our youngest daughter. It's true, the hospital can be a network provider, but the individuals don't have to be. In our case, the hospital was, along with one of the doctors, but not the tech or the lab that performed the bloodwork. I was a contractor at the time, and used a 'minimedical' provider through my employer. After it was all said and done, it would have been CHEAPER to not have the insurance and just paid the bills out of pocket. Their coverage versus premiums was upside down and I didn't catch it. I assumed that the $400/month I was paying would provide full coverage, but individually, each member of the family was only covered up to $1500/year. I paid them for 9 months. You do the math.
AllstateAtWork sucks for big emergencies. They're not that much better for routine well being though either.

[72Blazer]

You went to the ER in a hospital that is in the group.I'm guessing the $1100 was a co-pay. As for the Dr that sent you a bill because he was out of network,the burden falls on the hospital,not you to pay the Dr.You can't ask everyone at the ER who sees you if they take your insurance.Since the ER was in-network the hospital has to pay the Dr.Don't accept anything else.
You have to remember even though the hospital is in the network,not all the doctors that have privileges at that hospital accept your insurance.But since it was an ER visit the hospital will pay the out of network Dr.

[JeremyH]

The reason you get a different bill from other doctors like the anesthesiologist is that they are typically NOT employees of the hospital. Most of them work for a group of them and are contract employees with the hospital.

You need to speak with the hospital's billing department. Just like ANY other product or service in this country, the cost IS negotiable. Remember, the hospital would much rather collect some money than no money.

[dont slow down]

Originally Posted by JeremyH

The reason you get a different bill from other doctors like the anesthesiologist is that they are typically NOT employees of the hospital. Most of them work for a group of them and are contract employees with the hospital.

You need to speak with the hospital's billing department. Just like ANY other product or service in this country, the cost IS negotiable. Remember, the hospital would much rather collect some money than no money.

Yes the doctor works for a "group". That is who we are getting the bill from. It doesn't make any sense to walk into an "in network" ER and then when the Dr. comes in ask again if they take our insurance. Should the group have sent the bill to the hospital?

Originally Posted by 72Blazer

You went to the ER in a hospital that is in the group.I'm guessing the $1100 was a co-pay. As for the Dr that sent you a bill because he was out of network,the burden falls on the hospital,not you to pay the Dr.You can't ask everyone at the ER who sees you if they take your insurance.Since the ER was in-network the hospital has to pay the Dr.Don't accept anything else.
You have to remember even though the hospital is in the network,not all the doctors that have privileges at that hospital accept your insurance.But since it was an ER visit the hospital will pay the out of network Dr.

I don't think the $1100 was a co-pay. I've always paid a co-pay the same time as the visit, not a month later. We paid $0 on the day of the visit, which also didn't make sense to me.

[JeremyH]

I was talking with our billing department yesterday (they file and dispute medical billing all day long) about some stuff yesterday and thought it was relevant here. One interesting fact that one lady mentioned is that it was reported that 50% of medical bills have incorrect and extraneous charges on them. It is advisable to ask for the CPT code number (typically a number with 5 digits) and to look them up on the internet. You can read an exact description of the code that was billed.

It is also a good idea (when dealing with private insurance companies) is to check out what their allowable rate is for these specific codes and to compare them to what the Medicare allowable rate is for the same codes. MOST insurance companies will be comparable OR lower than Medicare.....rarely ever higher.

[dont slow down]

Interesting. I'll have to look the bill up and check that out. We are still unresolved with the doctors group. Thanks for posting that info up.

[JeremyH]

BTW, ALWAYS ask for a discount on the bill!! Also, make sure you ask when the due date is (if it's not printed on the bill). If they dont have a hard date, then send them a check for $0.15/month....