Question
What is the name of your state? Oregon
A year ago my boyfriend had a vasectomy. He is insured. He called around to different clinics and checked pricing and scheduling. He decided on a Dr who was charging an average fee for the area, $535 for the procedure and $45 office visit. He scheduled and had the procedure. a month later he recieved a bill which included a fee of $805 additionally and they call it a facility fee. This fee is only charged to people who pay for and carry insurance, the actual procedure would have cost us less had we not filed on his insurance. This fee was not disclosed before the procedure. We are now being sued by a collection agency, he has been to mediation twice and we feel we are right but I need to know the law on this matter.
Please help us defend ourselves against this.
PS. I now realize it isn't the insurance companies who are putting the screws to us, its the medical professionals putting it to them.
Answer
If he has insurance, what reason did they give for not paying the "extra" fee?
And I have to say, it's refreshing to see that you're the one in charge of clearing up this snafu for your boyfriend, especially after he got his boys snipped for you.
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It's illegal/fraudulent to charge for something simply because the patient has insurance. The "facility fee" is a normal part of most surgical procedures whether they are done in the office or an operating room. I don't know why they wouldn't disclose it before the procedure but they should be charging the same thing whether you have insurance or not.
Have you submitted the bill to your insurance company?
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How do you know the charge is only charged to people who have insurance?
As well, as other posters have stated, a facility often has a seperate charge. Every hospitial I have ever been to does. The doc is often an employee within a facility that is allowed to charge seperately of any others but the facility does charge for its' costs as well.
The statement of this being a "clinic" would make me believe this to be the case.
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Yes this was turned in to the insurace co. they paid their portion but are refusing to pay the 'facility fee' because it is not a viable charge according to them. I took it a step further and called and got a quote from this Dr. saying I was self-employed and without insurance, and specifically asked if there were any other fees, They said no. I had them fax this to me. Now my boyfriend is in small claims court but we cant find any laws to defend our position that this seems fraudulant and discrimanatory. Any ideas on that?
And BTW he did the snipping for his ex-wife, just b4 she left him. I myself had my tubes tied years ago. LOL
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And I forgot to mention ... during mediation their rep says that it is in fact a fee only charged to insured patients.
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Well that's why your insurance denied it. I know my policy booklet states that it specifically exclude any charges billed solely because the patient has insurance. But they shouldn't be allowed to charge you for it either. Was the facility participating with your insurance?
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Yes I fully understand why the insurance didn't pay, it was a bogus charge. And yes they do participate with our insurance company. And yes they only charge this to people who have insurance not to those who don't. My boyfriend represented himself in small claims court and basically has the judge now scratching his head over the matter. He had to take it under consideration and will send out a judgement. He actually said to the judge in his presentation that this was fraudulant and discriminatory billing practices and had about 2 minutes of his statement 'stricken from the record'.
Anyway, it seems that most all of us concur that this is at the least unfair, and at most fraudulent and or illegal practice. Now for us to follow up on this we need to be able to show an actual law, not just our opinion. Does anyone out there happen to know of one that applies? We did find out that the medical profession is outside the laws pertaining to contract laws for some reason.
Any help or direction would be appreciated. Thanks
Answer
What you really need to look at is the contract between your insurance and the facility, because that's what tells them that they're not allowed to bill the patients for charges that the insurance denies for this reason. The same way they can't charge you for items that your insurance deems "inclusive" with another item, or for an amount over the contracted rate for services, or for claims submitted after the filing limit.....but I'm certain you won't be able to get ahold of that. Try talking to your insurance company and see if they can give you any more information about the charge. If you can get an explanation of benefits showing where they denied the charge and the reason, hopefully also stating "you are not responsible for this charge", that should be helpful. Good luck with the ruling though!
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I would also check with the state insurance division and ask the question. Call Information: (503) 947-7980 and explain the situation. They may or may not have an answer for you.
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Thanks everyone for the great advise. I really appreciate it. I will continue to follow up on all this and post the outcome in case anyone else has the same problem. We have asked the insurance board to look into it by filing a complaint. And we are trying to get some more info from our insurance company as well.
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Hopeful (OP) who is the health insurance carrier? (I might be able to help depending on the carrier).
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The carrier is Cigna.
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Well my boyfriend took all the info we had gathered and went to small claims court. The judge decided that the case should be dismissed. I consider that a win. Now we would like to follow through with the clinic so that they can't try to overcharge insurance companies and or ruin the credit of hard working people. Does anyone know how we could go about that?
Answer
You could make a complaint to the board that regulates the practice.