i had this happen to me while i was in therapy after my father passed away suddenly.

while the therapist told me that the insurance company only paid her X amount and she would bill me the difference, i didn't understand that was unusual until i called my insurance company and asked them why my copay was so high. they called the doc and a week later i had the difference back in my mailbox in check form. needless to say, i didn't go back.

the insurance company told me they would've dropped the doc from their plan had she not given me back the money.

This happened to me 10 years ago when I was in college. I was having some issues and wanted to see a counselor. Because I wasn't living at home I contacted my insurance provider to get documentation that I'd be covered if I saw the person they required me to see. They authorized five visits; I stopped after three. When I got home that summer I started getting bills for over $300 from the clinic. Thankfully because I'd gotten permission in writing beforehand, all I had to do was produce the letter. The insurance provider had a mediation meeting about which I was not required to attend, and they paid the bill. But for those several months that I kept getting collections letters, I was almost frightened into paying it myself just to "get it over with."

I think our dentist is doing this. Every single time we have anything other than a cleaning done they bill us for much more than our EOB from the insurance company says we are responsible for. This is AFTER they have received the check from the insurance company. Every time it happens I have to fax the EOB to the dentist as proof. I'm sick of doing it, need to find a new dentist I guess. I knew we were not supposed to pay more, but I didn't know this practice was illegal.

This happens to me every time I go to the ER, because the doctors there typically are out-of-network doctors. It's evil and stupid and I hate it, but there's nothing I can do - the law appears to only cover this situation if the doctor in question is in the managed care network.

About a month ago, I had some form of food poisoning. I didn't have any medical insurance, but I was supposed to be covered through a special "handicap" service. All I had to do is fill out some paperwork. Within the first week, we got a bill through the hospital stating that we were supposed to pay x amount of dollars per month (which was actually twice the alloted money you could pay). We called the hospital to try and straighten the matter out, but they acted as if they never received the paperwork. We called the company back to see if they were supposed to cover it and found out, and I'm not kidding, their "computers were down and it would take another two weeks to straighten out the matter". Since the total of the bill is divided out, we had to basically tell everyone to hold on until the company recovers the information. On the positive, within a month they were able to get the paperwork over and get the bill officially paid.

Just happened to me last month after going to ER for some MRIs. But it was at an out-of-network ER, so I figured I didn't have much of a case to battle it.

I paid it, thinking I don't really have an excuse. I have insurance but went to an out of network ER for something that wasn't really an emergency. If I was more proactive I would have a primary care physician who could have referred me to an in-network neurologist.

BTW, how about hospital charges on MRIs? That's an eye-opener. It knocked me off of the high-horse used to ride about people going into debt...

About he only good thing I'll say about CIGNA is that they are very supportive of patients and aggressive when this happens. I had eye surgery, and CIGNA paid their contracted rate, minus my out-of-pocket deductable. The Explanation of Benefits they send for each visit clearly states that once CIGNA pays, the provider can't bill you for more. The anesthetist billed me for more than the contracted price, and CIGNA sic'd their lawyer on his office. End of harassment.

This happened to me with my midwife. I paid what I was supposed to pay, but then they tried to "negotiate" with her for the rest. I use the term loosely because they basically said, "We'll only pay you this percentage, too bad." Then she tried to get me to pay the rest. I don't blame her, she's got bills to pay. So she just upped her prices and sent them a new bill, so she got her money in the end. (Yes, I know that is illegal, but jeez, they should have just paid up.) The stupid thing was that this "insurance" isn't really insurance, because my husband's company has to pay the balances in the end. So what were they trying to do??

If you are in a PPO or HMO, and your provider is in the network, they are obligated to honor a set price. They violate their agreement (and the whole point of a PPO or HMO) if they try to bill you the difference between their regular rate and the PPO/HMO rate. That doesn't mean that they won't try, either due to bad accounting or just plain sliminess.

Just reading some of the comments about ER visits and not having a primary care physician...I'm not yellin', and I'm not pointin' fingers, but you do realize that using an ER as primary care contributes to higher medical costs for all of us, don't you? Also, having a regular primary care physician generally means you'll get better care, since she can get to know you and treat you better.
Getting off my high-horse....

So if I understand this correctly, my wife's regular OBGYN billed us for the difference in their rates and the insurance-approved amount for her recent check-up. Given the Dr. being in-network and it was a routine visit, we shouldn't be paying the difference here, right?

I just want to make sure that it isn't just out-of-network and ER kind of visits to watch here.

thanks

I have one that is still ongoing from 2 years ago...they just can't seem to get it through their heads that insurance pays the bill, not me. I am not that far from taking them to court over the matter...(and they freakin' called CPS on us to boot! Never mind the fact that the doctor was an asshole who thought setting an arm PRIOR to taking a fucking XRay was a good idea. Oh, and thank Bush for removing my right to sue the fuck out of them for causing harm to my son!)

@Sir Winston Thriller: Oh, I understand. But where are the chances better of hooking up with a hot coed internist? As you're lying there uncomfortably wearing a hospital gown. With an IV in your arm...

My ER trip incident has gotten me to go out and get a primary care physician.

Wait, isn't this how it's supposed to work? Hospital bills the insurance company, insurance company pays their share, I get a bill showing the standard rate, the insurance contract adjustment, and the difference, which is my responsibility. If I think the insurance company didn't pay correctly according to my coverage, I call them and they fix it or explain it.

On a related note, I've had pretty good experiences with United Healthcare. Had a doctor's office that didn't bill in time, so UHC refused to pay them. The billing company gave me all sorts of reasons why I needed to take care of it. United told them to suck it and they went away.

Healthcare costs are one of the few things that drive me beyond nuts - enough so to actually create a Consumerist account to comment!

About six months ago, some routine lab work was performed and I received an "Explanation of Benefits" (EOB) statement from my insurance, as well as a bill from the lab outfit. Of course the member's responsibility amount from the EOB was about 5% lower than lab bill amount. As an experiment to see what would happen, I paid about 3% less than the EOB amount (remember, bill > EOB > amount paid). So far, no follow-up bills or collections (well, we are talking about a dollar or two less here!). It would be interesting to do a follow-up with larger dollar amounts.

Frankly, I'd like to see posted prices and rates at healthcare provider's offices. It's probably wildly impractical and would cause the fall of the free world, but at least I'd know with certainty how much a procedure costs!

@rpm773: Wow, how much was your bill? An outpatient MRI/MRA once cost me $3,800 out of pocket...until I wrote to the VP of my (completely BS) student insurance company.

I can't imagine what an emergency one would cost, then!

@pjsammy: I'm pretty sure they can't do that as an in-network provider. They obvious can bill you for deductibles and coinsurance, but not a difference in their rate vs. the negotiated rate.

Okay, I didn't RTFA before and the summary is a little misleading. It's not insurance companies failing to pay the bill, it's doctors offices not willing to accept the 'discount' rate they negotiated with the insurance company.

I wasn't concerned before, but I am now.

That, and I am still fighting bills with my doctor's office on a weird technicality... My doctor opened her own practice and said she was still in-network. Insurance says no, she signed up two months later. Guess who's holding the bill right now? Yep, it's me!

@Crymson_77: What are you on about? We're still waiting for tort reform to happen. You have every right to sue today as you did three years ago, at least according to national legislation. If your own state did something stupid to the laws, you can't blame the federal government on that. ::rolleyes::

What about the form that every healthcare provider makes you sign about financial responsiblity, (that I agree to pay if the insurance company doesn't)?

I understand their need, as sometimes insurance may be declined or invalid, but does this waive our rights to not pay any insurance shortfall?

@jurijuri: I can't imagine that they should be able to bill you for the difference between in-network and out-of-network if they actually misrepresented their status. Of course, it could also be your insurance company that is lying.

@pjsammy: It all depends on the situation. If your doctor has an agreement with the insurer with a payment schedule to be charged for certain procedures, then the doctor can't collect for more than that amount. But, say you have a 20% co-pay. If the doctor normally charges $100 for a procedure, and the insurance contract says $80, but you have to pay 20% co-insurance, then the insurance co. will pay $64, and you have to pay $16 (the diff. b/w $80 and $64), NOT $36 (diff b/w $100 and $64).

Now, if the insurance company doesn't have an agreement (i.e., you're "out-of-network"), then you will have to make good the full difference between the doctor's normal fee and what the insurance company pays.

Some doctors have discounts for paying in cash. So, if you're out-of-network, pay cash, get the discount, then submit to the insurance company.

@SkokieGuy: Don't think so. I think that just means you'll pay if the insurer refuses the claim, and that you'll pay your deductible and coinsurance. I don't think they can just bill you for whatever they want above what their negotiated rate with the insurer is. They'd be breaking their contract with the insurers.

Absolutely perfect timing for this post. My wife gave birth a couple of months ago, helathy baby boy. We have PPO BCBS of MI. I got several reports from BCBS a month ago indicating how much the hospital billed and how much they paid and how much I owe $0. Just last week I get a bill from Spectrum Health, an in-network hospital, indicating I owe them $600. Am I obliged to pay them the fee or are they trying to scam me for the difference BCBS didn't pay???

@balthisar: I live in Texas and Bush was the governor that screwed me. Of course I can blame him, ninny.

This happens to us on a monthly basis, at least. We just call Aetna and they give the provider a courtesy call to remind them to leave us alone. Aetna is great in that regard.

@johnva: I should clarify that I'm talking about in-network providers in my last post. I'm less clear on how it works with out-of-network physicians, except that I know my insurance pays a helluva lot less.

My wife gave birth to our son at the end of last December, and several weeks later we learned that the anesthesiologist that administered her epidural was an out-of-network doctor. Although the hospital was in-network, the anesthesiology group that the hospital contracts with was having problems getting our insurance provider to agree to a new contract. In that type of situation our insurance company will still pay as if the doctor was in-network, but they will only reimburse at the rate the insurance company feels is fair. The number they came up with was about half of what the anesthesiologist wanted, so the anesthesiologist's office contacted me directly to let me know I needed to pay up. For a limited time only, they say, I could get a 20% discount if I paid the other 80%.

This smelled like a rat, and I embarked on a quest. The insurance company (Principal, which was helpful the whole time) says that they will pay up to 3 times the rate of Medicaid for that anesthesiology (as opposed to other services which are usually 1.5x), but they couldn't tell me how that rate was calculated. The anesthesiologist's office was aware of this, although they said that the rate for Medicaid was practically nothing and that my insurance company was being ridiculous.

I was able to find the appropriate documentation on several Georgia government websites, and deciphered the cryptic code information in the billing statement. No matter what I tried, I couldn't make the numbers line up. It looked like the insurance company should be willing to pay up to 3 times what the anesthesiologist is asking for. A quick phone call later and I find out that the anesthesiologist didn't submit the "service time" correctly, which is a key part of the equation- they were off by a decimal point. After I called the anesthesiologist office back, they resubmitted the claim and got the rest of their money.

I never received an apology from the anesthesiologist who bad mouthed my insurance company the whole time while trying to strong arm me.

@IC18: They are trying to scam you. If you have a statement from your insurance stating that you owe $0, then that is how much you owe. An increasing practice by hospitals today is also to send out the bill to you at the exact same moment they bill your insurance. Double-dipping for the win!

I showed up on the day of surgery to have my kidney removed because of a life-threatening infection, and the receptionist called me up to the desk a half hour later to tell me the hospital needed 300 dollars immediately or they would cancel the surgery. This was absolutely a hundred percent news to me. Given that I was in pain and unable to walk, and left my debit card, checkbook, and all but a few dollars in cash at home like they TOLD me to do, what was I supposed to do then?

I called a friend, who got hold of my boyfriend, whose college-age sister lent me the money out of her tuition money for the next quarter (YES, I bloody damn well paid her back with interest the next week). What if I couldn't find anyone?

By the way these were the same jerks who came to my bedside while I was on narcotics, demanding that I sign payment forms. The narcotics simply made me too tired to restrain myself from telling them exactly where they could shove their paperwork.

@shimsham: My question is how do you effectively identify it on the doctors' bills? A lot of my bills from doctors are almost indecipherable, don't match up to the EOBs from my insurer, and are not itemized by what was billed for.

@IC18: I forgot to add that I have a $300 In-Patient Hospital stay Co-Pay only. So they are still billing me $300 more..

Don't know if this is related, but not too long ago I had a lab send me a bill for the full cost of some blood work. I called them and let them know it should be covered by my insurance, and they should send the bill to them, and was told that it was a technique they use to try to get insurers to pay in a timely fashion; if a subscriber calls them up and bitches that they haven't paid for some covered care, it gets processed faster than if the lab calls them directly.

I resented being drafted into helping them with their paperwork, but I can understand their frustration with the medical insurers. Health care reform won't happen in this country until we pull all the CEOs of the big insurers from their cars and beat them to death.

I had this happen just a few months ago with a minor surgery my daughter needed. We pre-qualified the surgery and United Healthcare told us we would just need to pay the $300 deductible and that was it. A few weeks after the surgery the hospital (O'Connor Hospital in San Jose) sent us an itemized bill showing that we owed nearly $1,500, which was the balance left after all the insurance deductions they did.

I contacted UHC. They were very responsive and told me that they would handle it. They sent a real letter to the hospital and cc'd me telling them that I only owed $300, period. A few weeks later we recieved an updated bill for $300. We paid and have had no troubles since.

Overall it was the best experience I've ever had with an insurance company, I was ready for a fight and totally surprised when they were actually helpful.

My tip to consumerist readers: if you've got a planned procedure coming up, call your insurer first and get an idea of your coverage and whether you have to pre-qualify. Despite being evil most of the time, insurers at least usually have people answering the phones who know the ins and outs of your coverage.

@Crymson_77: If harm was done to your son by something that the doctor did (or ordered), that is malpractice and you can still sue for that. How did Bush take away your right to sue? If anyone took it away (if they did), it was that wonderful Congress that everyone voted in.

wait - this is illegal? there aren't enough jails to hold the violators in my neck of the woods. some in-network physicians around here are even requiring cash (or credit card) payment up front before they even submit to the insurance.

@Evil_Otto: Or they could just be attempting to "double dip" (bill both you and your insurer) and commit billing fraud.

My state actually has automatic penalties under the law for late payment by insurers to providers. But my insurance still seems to pay late anyway most of the time. And the penalty is tiny (it usually is like $1.50 or something on a $200 bill). So maybe the penalty needs to be upped until it hurts them.

my husband had an emergency room visit around just before christmas of last year. the total bill came to just under $1000. we had a deductible and paid that when the invoice came. but that combined w/ the "negotiated" fee from our insurance company did not add up to the the total charge, so we got another invoice asking us to pay the balance. i got aetna if i was obligated to pay the balance and the csr told me "no". in fact, he was nice enough to call the hospital billing to set the record straight. it took two billing cycles and a couple of calls to get the hospital to lay off and stop asking us for payment. it seems that everything should have been taken care of when aetna had the conversation w/ the hospital billing dept. it just took them 3 billing cycles to rectify the situation.

@thelushie: I consulted with 5 different lawyers, all in the medical malpractice field, and was told in all 5 cases that there was nothing we could do. And that the reason we couldn't do anything was the recently added laws on the books blocking action against doctors that obviously shouldn't have a job....

@Crymson_77: Ohhh, name calling, classy. Still, governors do not have absolute power. There still are state legislatures. As popular as it is to blame Bush for everything including the sun not shining (as anti-intellectual as that is), you might want to try blaming all the parties that are involved in the decision making process.

I'm having trouble with this from my allergist and am now in collections because of it. My allergist never billed me, they just sent me to collections. This is money the insurance co. owes them, and the insurance co. has admitted this and said they will pay if the allergist will resubmit, but it is easier for the allergist to send me to collections and send me a nasty letter firing me as a patient for being such a deadbeat.

My story is similar to many above: We received a "balance" bill from one of her doctors to cover what the insurance company had not paid. I was ignorant, though, and went back and forth between the doctor and the insurance company many times. The doctor was nice and would agree to "re-bill" the insurance company, at which time the insurance company would confirm they already paid the bill. After many calls to Unicare, I finally got the "right" CSR who told me they paid the negotiated rate and that the doctor should not be charging me any more. They sent a letter to the doctor to this effect and I stopped hearing from them.

Moral of the story: Educate yourself, and keep calling until you get someone who knows what they're talking about. Don't take "I don't know" for an answer.

@Crymson_77: What exactly happened to your son?

Let's not turn this into a tort reform debate, folks. Keep it on topic, please!

This is slightly different from the post, but it is related to shady billing practices.

I was recently injured at work and had to visit both the local ER immediately and later my PCP. Both were given workmen's comp insurance information for billing. The hospital didn't receive a response from the insurance company, and when it wasn't paid, they sent me a bill, with a note explaining it wasn't paid and to call the billing department. Turned out they didn't update my billing information when I called them back after leaving the ER. No big deal, and easily fixable.

My PCP was worse. They sent me a bill immediately for the visit, with no notes. When I called their billing department, I found out that for all accident related visits, they bill both the insurance and the patient immediately, because sometimes the insurance doesn't want to pay for a while. Um, what? To me, that seems an awful lot like double billing. The person in billing told me I can just ignore the bill for 3 or 4 months if I want... plenty of time to make it past due. It'd be enough to make me want to find another doctor, but I'm already working on that. (The doctor's commment of "What do you want me to do?" when I told her I was having servere, delerium inducing head pain in certain, specific, job required situations 1 week post-concussion was the straw that broke the camel's back. When a doctor says "that's odd" and "that doesn't make sense" about your head pain post-concussion, and recommends ignoring it, something is not right.)

Doesn't every single hospital do this? I have honestly never seen a provider (that was not your regular doctor) actually bill me for the correct amount. I know exactly what my deductibles are before I even go to the doctor, and I know what hospitals in my area are in-plan and out.

I always pay my deductible at the point of service, and basically ignore any invoices that I get.

I am a breast cancer patient less than one year out of Chemo. My Oncologist has been balance billing and although has received over $80,000 in payment. The balance is over $12,000 and I was just informed that due to this balance, I am he will not see me unless I pay a chunk of the bill.

I am sorry for the office assistant who had to deliver this news to me, and
sorry for a doctor who practices medicine in a world where patient care is
secondary, or maybe tertiary.

I have explained to him that I am not working, I am raising my daughter full
time. My husband just opened his own business, we are cash poor and already
in credit card debt just to keep afloat. I am sure this is all temporary and
in a year I will be able to review the balances and pay the portion that I
actually owe. But to refuse my three month check up to make sure I am
cancer free? What am I supposed to do now?

THE MD WHO REFUSED TO SEE ME!!!!!!

Dr. Jeffrey Tepler, MD

310 East 72nd Street

New York, NY 10021

212-650-1780

Angry cancer girl.