When insurers don’t pay the full amount of the bill, health-care providers are going after patients to make up the difference. It’s known as “balance billing,” and it’s often illegal, BusinessWeek reports. Under state and federal laws, doctors and hospitals generally need to be dealing with the insurers, instead of pressuring vulnerable patients. Have you had any success with fighting balance billing? Leave your story in the comments.
Medical Bills You Shouldn’t Pay [BusinessWeek] (Thanks to Eric!) (Photo: jgodsey)
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Hello,
I feel lucky i live in Canada, i have never ever seen a hospital bill for anything.
i only once got a bill for the dentist for 25.00 for missing an appointment but i knew that was comming, i have not recived bills from the dentist for any work done.
@waystland: I am on the other side of the coin. I am a Canadian who recently moved to the U.S. and I’m TERRIFIED that I’m going to end up getting eaten alive by the U.S. health care system before I even know what’s happening…
Anyone have any tips for someone who has NEVER used U.S. style healthcare before? I have a feeling it will be a rough transition.
@dragonfire81:
get insured in Canada, did you move there for good?
if not you are still Canadian
Stories like these make my glad to live in Canada, The only medical related bills we get are dental work (depending on province) and glasses. Fortunately almost any job you have covers dental and at least part of your glasses.
I am a near professional insurance user since my 17 year old sons first open heart surgery was when he was 5 days old. And he has had 4 more plus some other surgeries and many cath lab procedures since. Nearing $950,000 so far.
Deductibles, co pays, expenses, gas, parking, etc. almost bankrupted us. But I don’t think we ever paid more than the EOB required.
That took some work. But I’m sure it saved us a fortune.
Had a surgery a few years ago. Anesthesia billed separately, and as I’m reading the other posts, not an uncommon thing.
My insurance covered things pretty well and I set up a payment plan with the hospital for my portion. But since other services (anesthesia, x-ray) bill separately, I couldn’t finance in one big lump.
I got a bill from one of them after I met my deductible, called my insurance, who walked me through line by line of all they were billed for and how I didn’t owe that bill. Called the billing office and the woman SCREAMS at me, telling me I have to pay it or I’ll go to collections. I explained that I didn’t owe it, it was owed by my insurance and asked her to re-send the itemized bill and she refused, saying they had already sent a bill.
Threatening people with money they don’t owe, refusing to send a bill, all while someone is recovering from major surgery. Just wrong. And the refusal to send a bill? I believe that’s illegal. Definitely felt like extortion at the time
@ScarletsWalk: Nail them with a lawsuit and you can collect statutory damages over those kinds of billing practices.
Happened to me about 6 months ago when I had knee surgery. I was getting bills that far exceeded my responsibility. After getting run around from both the insurance company and the hospital/doctors billing dept (one of the few instances where both bill through the same office). I decided enough was enough and wrote an EECB to the entire hospital board (university affiliated hospital, so since im a student at this university, all i needed was a name to get their email and direct office phone number through our online system), the entire board of the local version of the health plan (it was an out-of-area, but still in-network set of claims), and the entire board of my local version of the health plan. The next day the home plan called the local plan, and both of them conference called the hospital. Then after sorting everything else out on their respective ends they all called me (4-way call) and apologized profusely. Each then separately followed up about two weeks later to ensure I had received corrected bills and that everything was correct.
I seem to have a similar problem. Any advice? I had to see a dentist this year and specifically got insurance to cover it (the most expensive insurance available through my job). Well, my network had the closest PPO dentist as being listed in another town about 12 miles away and they wouldn’t even accept me as a new patient! They refused! The next one was 24 miles away which is, of course, too far for me to even consider driving to. I decided to go with a Non-PPO dentist and now I’m getting the balance billing too. Is there a recourse for this? I feel like my insurance provider should have more dentists listed on their network; not that I’ll be able to do anything about it of course.
@nix-elixir: It’s my understanding that when you’re out of network the office may balance bill you – they have no agreement on contracted fees that in-network providers have. Sounds like your only recourse is to pay your bill. ,,,maybe driving 24 miles to the in-network dentist would be worth it:)
BTW, I have a deductible and have met said deductible.
A lot of people hear are describing normal co-payments and the extra cost of going out of network. If you see a doctor out of network your insurance company does not have a contract with them. Thusly your insurance company (and in turn you) are responsible for paying that bill. Balance billing is illegal, but if your contract states you have to pay 20% of your bills (like mine does) you have to pay 20%.
Ok, work in the medical field (durable medical equipment) and unless you are going to Bob’s House of Medicine this practice is pretty uncommon. Medical billing is crazy complicated.
Companies know what insurances pay for goods and services. Based on the HCPC code of the good/service and your copay, they know what the insurance will pay before the submit the claim. Normally they will bill for the exact amount that the insurance will pay, so if you asked the insurance they will say you owe $0.
Medicare has very strict rules about this, patient’s files are very detailed and if medicare was to audit them they would be put out of business.
Not to say billing errors don’t happen, but they are just going to be honest mistakes.
From the article:
“AMA member David McKalip, a neurosurgeon in St. Petersburg, Fla., says patients can trust doctors to behave ethically and not gouge the poor: “Doctors will know up front which patients are willing to pay” beyond what the government reimburses.”
HAHAHAHHAHAHAHAHAHAHAHHAHAHAHHAH
This has happened to me several times. It takes literally months of phone calls and letters etc. to get it straightened out. I didn’t know it was illegal (or had a name)… frankly i just thought it was common practice in the industry. Figure hospitals and insurance companies both love it…. I’d love to see a Consumerist article about the laws that make this illegal, so I have something to cite when it happens again… like you’ve done for debt collection problems.
OK, so what happens in this situation (timely article, this is, I was just dealing with this this morning!): On vacation out of state (in D.C.) I had to take my daughter to the ER — she hit her head on the hotel coffee table and had a nasty cut just over her eye. The hotel called an ambulance — total overreaction on their part but having no idea where the hospital was, screaming child, nervous hotel staff, etc., we went.
When we get home I get a bill from the DC ambulance service. I fill out my insurance info and return it (BCBS of Rhode Island). BCBS paid the ER, doctor, and hospital bills just fine, we paid our ER copay to the hospital, I thought we were all set.
Weeks later I get a bill from DC Ambulance where BCBS has paid about 2/5 of it, leaving a $330-some balance (yes, the full bill was $530 for a three mile, 10-minute ambulance ride with no emergency services provided, plus a separate $18 for mileage! Basically a really expensive taxi ride). Really should have just taken a taxi but you try telling that to your frantic wife and screaming 3-year-old.
Anyway, BCBS denies responsibility for the remaining balance saying the DC ambulance service (a city service, not a private company or anything) is not a “participating” provider.
Rhode Island law says ” § 27-41-26 Enrollee liability. – No enrollee is liable to any provider for charges for covered health services, except for amounts due for copayments, when provided or made available to enrolled participants by a licensed health maintenance organization during a period in which premiums were paid by or on behalf of the enrollee.” (see: [www.rilin.state.ri.us])
Can’t find anything on DC law so far. Which applies, RI or DC? And does “any provider” in the law mean ANY provider, or just any in-network provider?
@thomas_callahan: If they’re not a participating provider, they have no contract with your insurance carrier, and can bill you the balance. The law you quote says “No enrollee is liable to any provider for charges for covered health services” – problem is your insurance is saying this isn’t fully covered (b/c it’s out of network). You may be able to work out an arrangement to accept less $ with the ambulance provider, or you may appeal the decision with your insurer.
@hillsrovey: Thanks, that’s what I figured, I just find $530 for what they did to be ridiculous. A couple of 20-something EMTs glancing at it, shrugging their shoulders and saying “I dunno, might need stitches” should not cost $530, and driving me three miles should not cost another $18. They didn’t even bandage it or anything, and start to finish it took them well under half an hour.
@Crymson_77: I know, I know, and in hindsight given what little I knew at the time I’d make the same decision again. But had I known the hospital was only 3 miles away I would have opted for the cab… I have appealed but I’m not holding my breath.
It does hurt though, and feels distinctly “unfair” somehow given that I wasn’t told the hospital was basically down the street, had no way of knowing how much it would cost, etc. — I’m considering writing to the hotel since I think they only called the ambulance to cover their own a** when it clearly wasn’t necessary, but that’s probably more trouble than it’s worth.
@thomas_callahan: That may even be your out. Write a letter to the hotel and lay it all out. Request they pay the difference as it happened on their property and they should have known better. You are a good person btw…most people would have thought of suing the hotel before even calling 911…
I have been through this so many times for so many different reasons….
Recently had a bill for the doctor at my husband’s ER visit, in network – The bill was $655, the insurance paid $235 and the doctor’s office wanted the rest, despite an EOB saying I did not have to pay. I called and explained this, but the accounting person had the nerve to tell me, “Well, $235 is really an unfair amount, it is much less than we can accept. I’m sure you understand.” I called United Healthcare right away, and they conferenced me in with the office. The office was MUCH nicer to them, and took care of the balance right away!
Another example… I gave birth to my son at a network-hospital using network providers, but a specimen (retained placenta) was handled by a non-network pathologist, who billed me $700… UHC helped me fight that one too.
One time my husband got sick on a flight from FL to NY. He mostly slept on the plane – but when we arrived, he was having chest pains and the airport had him sent to ER… I got a bill for $800 for medical services rendered in the airport (basically, listening to his chest with a stethescope and calling paramedics to transport him) and I gave them my insurance info. Months later, I got another bill. Apparently they had not submitted the propery documentation to the insurance, so they were denied payment and wanted the $$ from me. They hounded me for months. I finally sent them a cease and desist letter…
I agree with the poster who said never ever pay until you are absolutely sure it is your responsibility!
If anyone is legally inclined, I too would appreciate some choice words that I can use in this all too frequent situation.
My in-network PCP, after a routine physical, where my $20 copay was paid on the spot, is now sending a bill for $37.
My in-network OBGYN, after my yearly check-up, where my $40 copy was paid on the spot, is now sending me a bill for $45.
From what I am reading here, what both of them are doing is illegal, especially if my EOB states that I owe nothing. Do I ignore these bills, or sic the insurer on them? Do I need to do this every single time? I mean, this is disheartening. I trust these people with my CARE, they know very private things about me. And yet, they aren’t above trying to gouge me, unsuspecting consumer, for more money? This isn’t just wrong, it’s unethical and violates the trust I had for them.
@rainbowsandkittens:
My first step is usually to call the doctor’s office and point it out to them. Sometimes it is an honest mistake and they will fix their records. (Or they may be trying to gouge you and hoping you wouldn’t notice – and will drop the matter if pursued.) They may ask you to send them a copy of the EOB for their files (they should have already gotten one from the insurance, of course). If they are insistent on you paying the bill, I would send them a firmly worded letter enclosing a copy of the EOB, and reiterating that you do not owe them any money, according to the terms of their contract with your insurance company. If it continues after that, sic the insurance on them.
Isn’t it mail fraud to send a bill knowing the person doesn’t have to pay it? If it’s a pattern at the company, isn’t this a RICO violation?
I had abdominal surgery (ruptured appendix) a number of years ago. All the doctors involved were part of the same large medical group with centralized billing. My policy paid was paying 100% since I had already met my deductible for the year prior to the surgery. I also had no copay.
Sure enough, I start getting bills from the medical group for the balance. At first, they tried to tell me that the amount was either due to my deductible or a copay. When I pushed it, I was told that since the insurance company doesn’t pay the full billed amount, I have to cover it. The main sticking point was the surgeon’s bill which was more than double the covered amount.
I called the insurance company, to discover that the amount they paid was because the code on the bill was for an appendectomy, not the more intensive surgery I had. They did say the would review it and pay the proper amount if the medical group submitted a corrected bill with a surgical report to verify.
The billing department refused to do this. I had a long recovery time with a number of followups. When I showed up for an appointment with the surgeon, someone from billing came up to his office and refused to let him see me until I resolved the bill. I told them I would come down AFTER my appointment. The nurse said she could not allow me to do that, since the system would not let them update my records until the billing hold was removed.
At this point, my mother, who had driven me to the office for the appointment, walked in from parking the car. Unfortunately for the person from billing, my mother is a paralegal and at that time was a patient ombudsman at the hospital down the road. She told the nurse to take me into the exam room as she grabbed the other woman’s arm and walked off to her office. Never got billed again, but they didn’t get paid either because they refused to submit a revised bill.
@felixgolden: Your mom is simply awesome. Wish we all had that when we need it!
I had a surgery, paid my portion, insurance paid their part, and received a zero balance statement from the hospital.
Here is the good part. Later, I received a bill from the hospital indicating that the insurance company decided that they wanted money back from the hospital, and they were going to bill me for this. This was based on the hospital renegotiating their contract with the insurance carrier.
I indicated to them they need to go back to the insurance company & get the money.
Don’t ever pay for a medical bill unless you are absolutely positive it is your respponsibility. Don’t get sick either.
I have been balance billed a few times and caught it right away. My insurance pays %100 after we meet our deductable and that is how I caught it. I called our insurance company and THEY called the hospital trying to balance bill me. It was resolved immediately with the help of our insurance company. I would suggest if you are being balance billed, call your insurance provider and tell them the situation. They will be most willing to help when they find out that it is happening.