Question
What is the name of your state? New Jersey
My son needed stitches and my pediatrician referred us to a doctor who happened to be working the hospital ER at that time. The stitches were done, and the doctor billed us a fair amount. The ER bill was submitted by the hospital to my insurance company first to see what they covered. I received an EOB from the insurance company and a bill from the hospital. Both list the billed amount as $341, and then list the insurance allowed amount as $627, with my total responsiblity being $627. I called the hospital thinking there was an error in the adjustment, and they told me that they have a contract with my insurance co that they can bill up to $647, and they therefore adjusted my invoice. In other words, had I not shown my insurance card, I would have been close to $300 richer. I'm being penalized for having insurance. I pay my premiums, but then pay more for service anyway. I called my insurance co, who told me that the hospital billed them $341, but they allow $647, so the hospital must have increased the charges after billing. Can they do that? Are they allowed to bill, and then increase the amount once they find out that my insurance company allows them to bill more?! Can I go back to the hospital and tell them that I don't want to go through my insurance for this service? I have a high deductible plan, so all this will come directly out of my pocket.
Answer
What is the name of your state? New Jersey
My son needed stitches and my pediatrician referred us to a doctor who happened to be working the hospital ER at that time. The stitches were done, and the doctor billed us a fair amount. The ER bill was submitted by the hospital to my insurance company first to see what they covered. I received an EOB from the insurance company and a bill from the hospital. Both list the billed amount as $341, and then list the insurance allowed amount as $627, with my total responsiblity being $627. I called the hospital thinking there was an error in the adjustment, and they told me that they have a contract with my insurance co that they can bill up to $647, and they therefore adjusted my invoice. In other words, had I not shown my insurance card, I would have been close to $300 richer. I'm being penalized for having insurance. I pay my premiums, but then pay more for service anyway. I called my insurance co, who told me that the hospital billed them $341, but they allow $647, so the hospital must have increased the charges after billing. Can they do that? Are they allowed to bill, and then increase the amount once they find out that my insurance company allows them to bill more?! Can I go back to the hospital and tell them that I don't want to go through my insurance for this service? I have a high deductible plan, so all this will come directly out of my pocket.
WoW! The only insurance plan I am aware of that can absolutely dictate anything is our government plan, Medicare (I'm not aware that they dicate what is billed, only what is paid!). Since that is not the case here, I suggest looking further. At issue will be the network contract between your insurer and the provider. I cannot tell from your post if you utilized a network provider. So, what this sounds like is perhaps an issue of Usual Customary and Reasonable charges that most health insurance plans will contain. I would also ask if this is the first medical claim for your son for the calendar year. Between both calendar year deductible and UCR charges, the scenario you describe is possible. But, I am only guessing. I think I may be fairly accurate based upon my experience, but please do provide more information. Can you provide the exact language and dollar amounts on the EOB? This would help me to help you very much. I can address your very last question by saying that I think it highly unlikely, very doubtful that not utilizing your insurance will lower the bill. Again, my primary question is if you took your son to a "network" provider. This is very important with regard to the right of the provider to bill you personally for any dollar amounts over the contracted and / or Usual, Customary and Reasonable charges.
Answer
Yes, we did utilize a network provider (both the doctor and the hospital). In ALL my experience (5 kids and all the medical care that comes along with their illnesses, accidents, etc.) I have NEVER had a claim submitted and then adjusted to a HIGHER cost since the insurance co has that higher cost listed as the usual and customary charges. This is not the first claim I've submitted for this child this year - he's a six year old boy and they get sick! My deductible is high and I haven't met it yet, but does that mean they can adjust my charges so that I just barely meet the deductible before the end of the year (and incur as much out-of-pocket expenses as possible)?
Here's the language on the EOB:
Billed Amt: 152.00 Allowed Amt: 0 Not Cov Amt: 152.00 Subsr. Resp: 0
Billed Amt: 189.00 Allowed Amt: 627.00 Your Deductible Amt: 627.00 Subscriber Resp. 627.00
The hospital bill states:
1 EMR Visit Level 2**************...189.00
1 RF-S-FACE etc**************.....152.00
Commercial Allowance B01 Blue Cross.....291.00
BX Denial/Zero Payment******************************************.....0.00
Small Balance W/O B01 Blue Cross**************.....-5.00
Total Charges: $341.00
Pymnts and Adjtmts: $286.00
Account Balance: $627.00
When I read this, I thought that Blue Cross allowed 291.00 rather than the 341.00, and that they made a mistake in applying the adjustment and added it rather than subtracted the difference. But, according to the A/R rep at the hospital, I was wrong - they "have a contract with Blue Cross that allows them to bill $627.00", therefore they adjusted my charges accordingly.
As a side note, another son ended up at the same ER several weeks later for stitches (OK, report me to DYFS!). Same MD, same hospital. I just received a letter from the hospital nofitying me that they submitted a claim to my insurance co - charges listed on this one were:
EMERG ROOM - 303.00
OTHER EMERG ROOM - 189.00
TOTAL CHARGES - 492.00
I'd love to see what they do with this one.
Thanks for any help!
Answer
judy,
I am rarely at a complete loss and without a guess at all. However, what you have posted does leave me so. Is it possible the hospital statement is including any prior charges? Even really old ones? Please don't be angry with me, I understand little ones getting sick. I also understand the angst of barely meeting or nearly meeting a high deductible each year. I really would like to help, but I am at a loss here. Have you called the provider and / or the insurer to question any possible, pure mistakes?
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Ok, sorry, I missed that one part of your post that indicates you did call, and their subsequent response. They may be "allowed" a certain amount according to a contractual fee schedule or some such. But, I'm guessing that your insurance plan language should / would contain something to limit the payment to the UCR, the billed amount, or the contract, WHICHEVER IS LESS. Again, I can only guess, using usual situations. Try to find your plan book and call the INSURER. Ask the INSURER to explain this again. I do believe that if you used a network provider, that contract would also include a provision to waive any amounts above the contracted amount. I'm so sorry, I wish I could figure this out and help you, but I agree, something does not seem right. Continue to call and question both provider and insurer until you understand. But, but don't let this ruin your credit. Post back with new info if you find it. lkc15507
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PS. I agree. I have never heard of a thing such as you describe. You obviously have experience tracking inusrance payments. Follow your gut and question, question, question. Also, no one would presume to turn you into child protective services. Kids have accidents. I simply agree that this seems wrong! lkc15507
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This is so odd! Normally, an insurance company will not disclose the allowable amount if it is higher than the amount billed by the provider. If you billed $100.00, but their contracted rate is $150.00, the EOB will state the allowable as $100.
Also, i was under the impression that the commercial rate that a provider bills is set and can only be changed once a year. You can't charge one patient w/ UHC $50.00 for a service and the next patient w/BCBS $100.00 for the same service because their insurance allows more. Your fee has to be consistent, with the exception of self-pay patients that you can give a discount to (as long as its not under the Medicare allowable if you participate w/medicare.)
Now, my experience is with a private practice, and maybe rules are different for a hospital, but hopefully someone with experience in that field will be able to confirm. Good Luck!
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There are no laws or regulations limiting the prices hospitals can charge, nor are there any prohibiting them from making a billing error and adjusting the claim.
You are not obligated to have health insurance claims filed on your behalf. You are free to self pay if you wish. Simply pay the hospital and instruct them to refund your insurer. However, it is doubtful the price will change.
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Thanks to everyone for your advice. I finally got someone at the hospital who knew something. (Yes, I did take down her name!) She admitted (although she threw the blame on the insurance co, rather than the hospital) that my insurance co has been messing up their ER claims all the time. Basically, instead of applying the adjusting the hospital's charge to the usual and customary charge and applying that to the patient's deductible, they have been using the patient's ENTIRE REMAINING DEDUCTIBLE as the usual and customary charge and sending that back to the hospital as if that was the charge. (So, if my son had not satisfied any of his deductible this year, I guess I would've been hit with a $1500 ER bill for the time he spent sitting in the waiting room, the little piece of gauze, the strip of surgical tape, and local anesthesia.) She said that the hospital was resubmitting the claim and that it will be resolved. I'm not breathing easy yet; but I will wait and see before I pay anything.