When is the right time to pay your hospital bill….anytime but at the hospital!
This has been a tough time for a HealthLink Advocates client with a chronic medical condition and a rather long list of physicians. A general practitioner, many specialists, and an ongoing treatment plan is required for this client to live a pain-free life. While the physicians have been able to make progress with some of the medical situations, looming in the background are the host of medical bills that are ever-present. A big question to ask: How much better can you feel when you have your pain under control, but are under mental stress and pressure, knowing that you owe thousands of dollars for that medical care?
While I can speak a bit about the medical progress, my area of expertise is insurance and so I thought I would share a little bit of this story, in hopes that it someday saves someone else from such a situation.
The Dangers of Not Knowing What Health Insurance Covers
This patient, so desperate for relief, decided to take a leap and travel out to one of the large, well-known major medical facilities in the Midwest. Not sure if they took her insurance, and not even sure of the effective date of the new insurance she had recently signed up for, she was desperate enough for the help that she put the financial restraints on the back-burner and goes for it.
No Down Payments for Hospital Stays!
Physically, there is some progress with her chronic pain. While not leaving 100% recovered, at least there is some relief. The plan is to head back to New York with its numerous medical centers and pursue similar treatment closer to home. Upon discharge, this is a discussion about the bill. To do the right thing, the patient decides to right there and then provide a $10,000.00 down payment toward the total bill – the bill which had yet to even have a total.
When the bill arrived, the total was large - $67,000! Well over the $10,000, "down payment", that the patient had already paid. Gulp! I am not sure, that with such a bill I could even put my head down on the pillow. While the total bill was just at that $67,000 mark, the adjusted bill, which reflected the $10,000 deposit paid in a "goodwill" effort at the time of discharge, came in for a total of $57.000.
An Insurance Advocate to the Rescue!
Needless to say, with this bill in hand, along with a host of other open bills, the patient reached out to HealthLink Advocates to see if we could help. That was in December 2019. More than eighteen months ago, and we are still at it. This patient, in intense pain, not only chose to go to a facility without knowing if her new insurance was yet to be effective, but she also did not (could not) stop to consider if the hospital would be in-network or not. Upon arrival at the hospital, she informed them that she was not sure if she had insurance and was admitted as a "self-pay" patient. Fortunately, after weeks of phone calls, etc., we were able to straighten out most of the nightmare.
Successful Appeal
After a little research, we learned the insurance that the patient had signed on to right before her trip out west was effective the day that she was admitted. While the facility was out of network, and there was no pre-approval of care for the facility out west, we attempted to appeal for relief, asking the insurance to grant an "out-of-network" treatment approval post-discharge. I am happy to share that we had success with that. The insurance company decided to consider the request, and after a lot of back and forth, approval was made for out-of-network benefits specific to that facility.
This was not easy. It took months and months of submission of paperwork to back up the necessity for treatment, as well as update phone call after update phone call to keep things hopping. It was a great day when the patient finally had that all-important piece of paper – an Explanation of Benefits (EOB) stating that she would only be responsible for $500.00 of that $57,000 bill.
Give Me Back My Money!
Now for the downside. In the months leading up to this point, the patient received bill after bill, notice after notice from the facility looking to collect. While she was tempted to start paying a bit at a time, she held out for the final decision of the insurance company. It was a lot of stress – and a lot of relief!
The problem……the facility STILL HAS HER $10,000.00! Yup. They have it. AND THEY ARE, THUS FAR, NOT GIVING IT BACK! The patient is not looking for $10,000., but for the $9,500 she would be owed after consideration of her $500.00 deductible.
It has been nine months since insurance has issued that EOB but be warned. Retrieving money from any medical facility that has been paid twice is a job in and of itself. Of course, if this hospital was in-network, this would all have been so much easier. If a hospital is in-network with an insurance company, the insurance company has a process in place to help you recoup your funds. They simply lean on the facility under the terms of existing contracts that are put into place when signing on for in-network status. It takes time, but it is usually successful.
The hospital's reasoning? They used the $10,000 toward provider bills that were not covered by insurance. Providers that are all out of network, but have facility rights at the hospital. The providers have no interest in submitting any bills. They already have their money. Not really their money – but the patient's money. This, of course, is all a tangle. The hospital only billed for their own open bills. These were the only bills considered by the insurance company – not the provider bills. In addition, as the providers are all out-of-network, and the facility is also out-of-network, balance billing rules do not apply.
So far, the insurance company continues to be helpful. They continue to try and pressure the hospital to return the "down-payment", but as previously mentioned, they have little clout without that in-network status.
Takeaways to Remember
The patient – has hopefully taken away several things from this situation. First and foremost, of course, is to STAY IN NETWORK. The next one being – not to prepay any bill (unless you have checked with your insurance company and they confirm it is a co-pay or deductible amount).
While the patient is relieved to have this bill behind her – along with the pressure of the monthly "past due" notices, it will continue to be a journey to collect that $9,500. With treatment ongoing, it could go a long way!