A Legal-type Question

[Markel]

A while back one of my kids was in the hospital. We made sure to use a facility that was under my health insurance's "preferred" list, and told the facility that we needed to use doctors that were on the insurance's list (which they did). They wanted to use a specialist for one thing and told us that there were having some trouble finding someone that was under the insurance's plan. They finally brought the specialist in and things progressed. Later, my insurance balks at paying the full amount since the specialist was not in their network. I explained the whole thing to the insurance and nothing got changed (they only paid $420 on the $940 bill).

Do I have any recourse? I never gave my approval for the hospital to go "out of network", and they led me to believe that they were staying in-network for everything they were doing.

I think that the specialist may have turned the account over to a collection agency. :mad3:

[Jeffbx]

I think it's totally going to depend on your insurance company. For example, back when I had an HMO (which suck rocks, btw) we had a similar policy. However, they had a disclaimer that if a specialist was necessary for care and there was no one available in the immediate area, you could get an exemption to go out of network.

Hopefully yours has a similar policy?

[Markel]

I'm in an indemnity plan, so I can always go out of network. However, in-network the providers have agreed to do the service for the amount that the insurance considers adequate (so that if the aforementioned specialist was in network, the bill would be reduced to $420). But out of network, I am responsible for the difference between the charges and the amount that the insurance will cover. The same thing applies to the hospitals (which is why I was careful to stay with approved providers).

[InfiniteNothing]

A. File an apeal with your insurance company and go through the apeals process
B. Write to the insurance department of your state (research online) and file a complaint.

[freebies4me]

A. File an apeal with your insurance company and go through the apeals process
B. Write to the insurance department of your state (research online) and file a complaint.

I work in the legal field and agree with InfiniteNothing as far as your first steps are concerned to resolve this situation. I would also obtain all medical records to see if anyone made any documentation.

Good luck to you!:thumb:

[Markel]

A. File an apeal with your insurance company and go through the apeals process
I've gone through the appeals. No success.

B. Write to the insurance department of your state (research online) and file a complaint.
I guess that's worth a try.

[InfiniteNothing]

It's actually not hopeless yet. They review the case, etc. Good luck.

[kgsilvas]

Don't recall where you live Markel, but do you have a "7 on Your Side" or some type of "investigative news" team on a local or regional TV affiliate?

Sometimes just a visit from a guy holding a mike with a camera behind him makes all the difference.

The insurance department is a good avenue too.

[The Happy Squirrel]

call cust service at the hospital or clinic and see if they have charity care to help with the bill
i got screwed by an iinsurance when my kid was born i worked in one town that was an outlying store from the rest of the chain, went to the only provider in town for the L&D and nothign was covered becuase we were out of etwork. That nefver stopped them from collecting the preimums every month but yeah
we applied for charity care they took care of a huge portion of the bil <several thousand> and i paid the rest while still fighting with the insurance company over a year later they finally agreed to pay and sent me a check for like 4500 which i then donated back to the charity it was more then they gave me but it was such a wonderful prgram and such a huge help that they deserved it for someone else in need

[johnnymk]

I am not sure who you have called. But starting over 1-1/2 years ago,I was getting numerous letters from my insurance company that I was responsible for bills I thought they were paying. It turns out that the left hand didn't know what the right hand was doing. Paperwork was lost or someone dropped the ball internally.

I had to call different numbers numerous times.

In one instance, the doctor couldn't get through to the insurance company that they were still in the network.

I would call numerous times to various numbers within the insurance company and the doctor to try and get it resolved.

[Markel]

I would call numerous times to various numbers within the insurance company and the doctor to try and get it resolved.
I have literally dealt with the insurance company dozens of times over the series of claims (and multiple times on this specific claim). Everything else was finally settled, but this one claim may be rearing its head. If I had $500 to spare I'd just pay it to be done with it (it almost throws me into depression every time I've had to revisit the mess), but as it is I'm at the point this month that I'm not sure if I'll have the means to cover the bills.

I'm not certain about the collection agency - I got a computerized call on my cell yesterday that I could hardly hear (particularly the name of who "it" was trying to contact). When I pressed '1' to take the "message", it went into a spiel about being a collection .I couldn't make out the company that "it" said the bill was for, and after it started out asking about how I wanted to pay I hung up on "it". But afterward I though about the amount that "it" said, and it seems that it might be the amount in question on this bill.

[chrissy]

call cust service at the hospital or clinic and see if they have charity care to help with the bill
i got screwed by an iinsurance when my kid was born i worked in one town that was an outlying store from the rest of the chain, went to the only provider in town for the L&D and nothign was covered becuase we were out of etwork. That nefver stopped them from collecting the preimums every month but yeah
we applied for charity care they took care of a huge portion of the bil <several thousand> and i paid the rest while still fighting with the insurance company over a year later they finally agreed to pay and sent me a check for like 4500 which i then donated back to the charity it was more then they gave me but it was such a wonderful prgram and such a huge help that they deserved it for someone else in need

There are several orgs that do this. Good possiblity there is one near you.

Also, call the hospital/specialist back. You might beable to get them to write the debt off. You will get a 1099 (I think) for your taxes because it's concidered income. Let them know you are in no way able to pay this bill and need either a payment plan or a write off.