Question:
Anyone know how ERISA fits into all this??

I had to go out of network for my lap DS. My ins pd 100% after my deductible and max out of pocket. However, they had an "audit" company (Principle Performance, TX) review the hospital bill since it was so high. They (audit co) determined that the charges were excessive (altho' NOT necessarily based on R&C) and said the hospital was billing for items I could not have or should not have incurred. They sent their findings along with a check (for only HALF of the $33K hospital bill!) to the hospital CFO showing the results of their audit and asking the hospital to "substantiate" or appeal this payment by providing them a copy of my hospital records, etc. The hospital has not done this and they are billing me for the remainder ($17K!!!). However, my insurance company assures me that even though the hospital was out of network, I am "NOT legally responsible" for the excessive charges and has sent me a letter via email to send to the hospital stating "there is a disputed balance as a result of billing errors and/or overcharges identified during my ins's adjudication process. I will not be resp for the amt in dispute and will only pay the undisputed amt under the provisions of my healthcare plan which is established in accordance with ERISA. It also states that if they try to collect or damage my credit becuz of this or bill me further, i will exercise any and all legal remedies, etc. . . " Has anyone had a similar situation and maybe letter and had it work? The ins tells me that the hospital has not even appealed the disputed charges with them (the ins co)! Or provided any documentation like a copy of my patient chart, etc. Should I go ahead and send this letter to the hospital along with a check for the remainder that my insurance says I "owe" (about $1000) and mark it "for payment in full"? I hear that can essentially make them accept that amount as payment in full if they cash the check with that notation on it. Any comments anyone? Thanks in advance! Blessings,    — ChristiMNB (posted on November 14, 2001)

November 14, 2001
I would go ahead and pay the amount the insurance company says you owe along with a copy of the letter. Let the insurance company and the hospital sort out the disputed amount. Unfortunatley, writing "payment in full" on your check will not necessarily commit the hospital from accepting the payment as full payment if they cash it. This happened to me once (someone gave me a check with the "payment in full" statement on it even though they owed me more money). My attorney said that you simply need to make the notation "Endorsed under protest" above your signature on the back side of the check. That, in effect, negates the "payment in full" statement. It may be different in your state. It certainly wouldn't hurt. Most people don't know about negating the "payment in full" statement. You should check with an attorney. But, in any case, I don't think you really have anything to worry about. The hospital and insurance company should be able to work this out.
   — Gina E.