Mitigating Medical Costs - Planning For Surgery

[EjGlows]

Erin - there is no delta. There is the insurance rate and the balance between the doctor and or medical group rate. It is perfectly legal for you to be billed both by your insurance out of pocket (according to your insurance policy agreement) and the medical group (regardless of in network or out of network) the balance between the insurance rate and the medical group rate. You dont need codes or the charge master unless you are deciphering a bill and yes you do have the right to see it. What is illegal (in california) is balance billing for ER services. That is the only time a medical group cannot balance bill. Everything else is fair game. So if your procedure is say 100k total and your copay is 80/20 and the insurance rate is $60k then insurance pays 48k you pay insurance 12k or your max deductible and the medical group bills you 40k. THAT is how people get stuck with big med bills even with insurance. Send your medical group a legal disclaimer that unless they provide an up front cost for this procedure by such and such date then they waive their right to balance bill.

Jake, I think we're trying to say the same thing. A doctor may negotiate a procedure for $x amount but bill a patient directly for $y. There is a delta between those two negotiated rates (assuming the patient negotiates) called balanced billing. There is also a pretty good chance that you will have to negotiate what the chargemaster charges for a good/service and what the market rate currently is. In all, the consumer if basically screwed.

 

[JakesKTM]

Jake, I think we're trying to say the same thing. A doctor may negotiate a procedure for $x amount but bill a patient directly for $y. There is a delta between those two negotiated rates (assuming the patient negotiates) called balanced billing. There is also a pretty good chance that you will have to negotiate what the chargemaster charges for a good/service and what the market rate currently is. In all, the consumer if basically screwed.

A delta to me means an intersecting trajectory between two points. But in my experience with balance billing there is no such negotiation or trajectory. They (not all doctors) balance bill what the medical group establishes as their rate minus what the insurance paid. That goes for "in network" doctors as well.

 

[UDRider]

You and Erin are talking about the same thing. Delta also means the difference. In your example difference between what the rate is and what insurance agreed rate is 40k, that is the delta.

The whole system is designed to milk as much money out of consumer as possible.

 

[corndog67]

I just did 15 days in the hospital, 7 in ICU, removal of my esophagus. I didn't research anything but my surgeons (baddest ass brothers in all of central CA, in my opinion). I'm real interested in the bills that I know are on the way. So far, $269 for surgeon bills (the first bills I've received since I got home), in fact, it never occurred to me that I could possibly do that. I used the hospital supplied tooth paste and brush, and basically everything else they offered me.

I'm betting that I approach $300k, plus the chemo and other stuff since this started in March.

Good thread EJ.

 

[EjGlows]

A very good morning to everyone! Finally, and update.

I was awakened by a call this morning from the UCSF billing department letting me know that I owed $9k from a visit in March! :wtf

Did I have a baby? No.
Did they cut my arm off and I've had a cyber limb since then? No.
Did I have two X-rays, a visit with an orthopedist, and an MRI with contrast? Yes.

The kind lady, Victoria (always write their names down) advised me that the hospital billed the insurance company and that they only paid the negotiated rate, with the balance due from the patient. This is where you stop, take a breath, and kindly request that you have your insurance company join the call. Once I had Alexis from Cigna on the phone with our buddy Victoria, the two of them went line-item-by-line-item, detailing out who paid what and what costs were negotiated, blah blah, blah. After a very brief discussion, it came to light that Victoria was unqualified to continue the call as she had dug a bit deeper and saw a note that this bill was "under review" - I was not being sent to collections, yet. Victoria left the call, and Alexis and I dialed the hospital billing directly.

Our newest trilogy now included Sandra, the billing manager, who was incredibly helpful and parsed my billing records quickly with Alexis contributing the exact insurance response to each line item. It was a remarkably efficient call, with the end result being a report generated that my balance was, in fact, $0. :applause

My next item of business was to check my OOP costs for my upcoming surgery, which I was given down to the cent. I also checked authorization and also if any OON providers were to bill for services rendered while I was under anesthesia and was informed that Cigna would file the claim to that provider and bill me for the in-network negotiated costs for services. This would fall under my OOP max.

The main takeaway from this morning's little episode is to connect the professionals as soon as possible. There's no way I'd be able to dig up all the payments, bills, adjustments, etc. from the file cabinet I have in my office. Even if I could, there's no way I would be able to interpret the documents - they're cryptic and misleading on purpose.

My final request to Alexis was if I could talk to her manager and sing her praises, I truly believe in making sure people get recognized for their good work (and I'm sure it doesn't happen very often in a call center).

With that said, I'm waiting on an OOP report for the upcoming surgery and am already nearing my max, so if things go as well as they did this morning, I should be out about $1k. Unless, UCSF's billing department decides to call me again...

--------------------------

WARNING! FRAUDULENT COLLECTION CALLS HAVE BEEN REPORTED: My insurance rep made sure to tell me that I should never confirm any payments prior to establishing that the bill was from an actual provider. When I first picked up and was told I had a balance I did NOT give any personal information before confirming that this was a legitimate phone call. Please be careful this season.

 

[afm199]

Nice work and thanks for the procedural outline. Good to know.

 

[Cycle61]

:applause

 

[UDRider]

Thanks for the info!

I had something similar happen to me a few years back. A year later I got a bill for 1k from Stanfurd ER. No real explanation. Called my insurance, they called Stanfurd billing. Never heard from them again.

The three way calling never occurred to me before. I will keep it in mind.

 

[rodr]

... After a very brief discussion, it came to light that Victoria was unqualified to continue the call as she had dug a bit deeper and saw a note that this bill was "under review" ...

The kind of ignorance that is fostered by corporate policies. What a bunch of crooks.

Nice work Erin.

 

[JakesKTM]

While I would like to think hospital billing departments are capable of being professional, the truth is the manager in this instance knows that balance billing is now under serious legal scrutiny if not outright banned.

Two cases: Prospect Medical Group, Inc. v. Northridge Emergency Medical Group (2009) and Children’s Hospital v. Blue Cross of California (2014) have pretty much put a kabash on balance billing. Read the last two lines of this attorney's blog as recent as August 27, 2014.

EJ - congratulations on the timing of your procedure. Others should not sweat this too much right now until this case goes to the California Supreme Court.

 

[JakesKTM]

The kind of ignorance that is fostered by corporate policies. What a bunch of crooks.

Nice work Erin.

The billing technician did not know the case law recently decided, my guess. But yes, crooks is right. If the case law were decided differently, EJ would owe $9k.

 

[EjGlows]

The billing technician did not know the case law recently decided, my guess. But yes, crooks is right. If the case law were decided differently, EJ would owe $9k.

Thank you for bringing this up! We have to keep in mind that there is a difference between balance billing and co-insurance, which can seem a bit confusing. I paid my co-insurance (a couple of hundred bucks) and UCSF was attempting to collect via balance billing. :mad

Their online records never showed a balance and I'm fastidious in the management of my bills, so this "pre-collections" call really raised my blood pressure.

This is exactly why I urge a conference call to work through the details. Be present and facilitate an immediate resolution. :thumbup

 

[JakesKTM]

Winning! Conferencing in the insurance provider to put the hospital on notice that a) you were the consumer caught between the insurance provider and the hospital b) the insurance provider was challenging the reasonableness of the bill going line by line. BEAUTIFUL! You just erased $9k of potential medical debt that MOST consumers would have buckled and paid. :thumbup

 

[mercurial]

If the provider is in-network and has a negotiated contractual rate with your insurance provider, they have privity of contract with that insurance company to bill at that rate and they are violating that contract if they come back to you and try to bill at a higher rate. You, in turn, have privity of contract with the insurance company that they will cover the procedure with X copay or coinsurance. If the provider violates their contract with the insurance company, implicitly the insurance company is now violating it's contract with you.

I don't know why anyone would let this happen to themselves, unless they were just naive. I wouldn't have even helped the insurance company talk to the provider, I'd tell them to figure it out on their own unless they want to hear from my lawyer and pay me alot of money to figure it out for them, in court.

 

[JakesKTM]

If the provider is in-network and has a negotiated contractual rate with your insurance provider, they have privity of contract with that insurance company to bill at that rate and they are violating that contract if they come back to you and try to bill at a higher rate. You, in turn, have privity of contract with the insurance company that they will cover the procedure with X copay or coinsurance. If the provider violates their contract with the insurance company, implicitly the insurance company is now violating it's contract with you.

I don't know why anyone would let this happen to themselves, unless they were just naive. I wouldn't have even helped the insurance company talk to the provider, I'd tell them to figure it out on their own unless they want to hear from my lawyer and pay me alot of money to figure it out for them, in court.

Do you have any citation establishing the privity doctrine in cases of balance billing as precedent? As far as I am aware the only two cases addressing balance billing in California are the ones cited above. I sure would like to know what loophole the hospitals used to legally justify balance billing, which up until this year, they did and still do.

I told the hospital to pound sand and they hit my credit report. Now I have to file a lawsuit to have it removed. :rolleyes or wait 7 years.... they will never sue me for it knowing they will lose.

 

[mercurial]

IANAL but as far as I know, the insurance company has privity with you to cover the service accordingly to explicitly defined copay/coinsurance structures. So the provider can try to do whatever they want, but in litigation whatever flesh they take from you, you are in turn allowed to take from the insurance company, and the insurance company would then likely have some sort of contractual right to take it back from the provider.

In your case, I would've alerted the insurance company to rectify the situation, and if they failed to do so, I would've sued them, and as plaintiff I would also obviously claim attorney fees as well as personal time required off work to sort the mess out. They, in turn, could decide to countersue the provider.

 

[EjGlows]

IANAL but as far as I know, the insurance company has privity with you to cover the service accordingly to explicitly defined copay/coinsurance structures. So the provider can try to do whatever they want, but in litigation whatever flesh they take from you, you are in turn allowed to take from the insurance company, and the insurance company would then likely have some sort of contractual right to take it back from the provider.

All of this may be true, but why put yourself in a reactive state? This thread is all about trying to control the situation and being proactive, a-la ounce of prevention. Collections is no joke, regardless of who is right or wrong, there's a lot at stake. I know have documentation from both my insurance company and the billing hospital as proof (both are sending me paper documents with complete notation of the phone session in their respective systems). :thumbup

 

[mercurial]

I would make money off the situation, so it wouldn't bother me too much, I don't think.

Health insurance is also heavily regulated by the state. In the past whenever I've had smaller claim issues (underpayment/misclassification of OON coverage, etc), I give the insurance company one written warning and then I file a formal complaint with the state regulatory authority and the issue usually gets sorted pretty quickly. That would also probably work well, in other scenarios of payment discrepencies.

 

[EjGlows]

Well, the deed's been done and I'm on the road to recovery. The bills are starting to come in and I thought it might be helpful to post one or two up and explain how to read the bill, explain my financial responsibilities, show how the insurance company tries to convey their plan details so that it reads as pro patient advocate, and as a cathartic exercise to get through the pain and suffering of having to shell out cash. :laughing

First off, I purchased an ice machine that counts as DME (durable medical equipment) that was prescribed by my surgeon. My provider required this to be purchased out of pocket (upfront) and I've submitted for reimbursement which will be paid out via check and will cover 90% the cost per my insurance coverage. I had to call the insurance company 3 times to get the correct form and for an explanation how to fill it out so that the payment would not go directly to the provider (as is the typical mode). I can see how frustrating this would be for someone that isn't organized or doesn't have the patience. I'll get a few hundred dollars back and it's worth the wait.

Secondly, I've reached my out-of-pocket for the year (yay!) and the additional bills for the anesthesia/post-op visits have been covered at full cost (no co-payments, etc). I'll show this in another bill so you can (again) see the language that Cigna chooses to use when explaining benefits.

Without further adieu...

 

[Bronto]

Heal up well :thumbup
Drink Milk it does them Bones good :teeth

Did excellent job keeping the medical costs down. An experience documented others can learn from. Thanks