Question:
Ins Co had outside agency audit hospital bill and then paid. Now what?
Hello Friends, Me Again! My hospital bill with Ocean Springs Hospital, MS for an uneventful 3 day stay was about $34,000. My insurance company found that to be awfully high and sent the itemized bill to an outside auditing agency. The audit agency did their work and claimed the hospital overcharged me and my insurance by about $20,000. I went out of network (had to, long story) but my ins co tells me these "excessive" charges are NOT above reasonable and customary, they are simply charges in excess in what I could have incurred. My Ins paid in full the charges deemed ok by the audit agency ($15,000)and sent a letter explaining the audit, along with the check, to the CFO of the hospital. When I got the EOB I called the ins right away and the nice lady there (that I've spoken to since day one of my start on this journey) promised me this was not a R&C issue and that I would NOT be responsible for the charges deemed excessive by the audit. I reminded her that they were out of network and wondered if the hospital would see it the same way! I called the hospital and a very snippy lady said that I would indeed be responsible for the remainder and that they did not honor ANY outside auditing and that the audit must be done on their own premises with their own internal auditor and that my ins co would need to call them and make arrangements to travel to MS and perform the audit!! (Hello! What ins co is gonna do THAT???) Well now, one month later, (and after requesting an audit of my acct myself with the hospital)I finally get the dreaded bill from the hospital and they say I owe it. WHAT CAN I DO?? The ins co is telling me I am not responsible becuz the hospital bill was excessive according to the auditor, but the hospital is saying I am!! I am terrified, I am scared, I don't know what to do or if these "external auditing agencies" have any clout??!! What's my next step? How can I appeal this? Anybody have their surgery done also at Ocean Springs (either IN or OUT of network) and can give me an idea of what they were charged?? And what their insurance paid? Maybe my ins co's auditor is way off base, maybe the hospital is! HELP PLEASE! Thank you and Blessings in advance....... — ChristiMNB (posted on August 27, 2001)
August 27, 2001
Yeah since you went out of network I don't see how your insurance can say
you dont owe it. The hospital has no contract telling them they can't
charge it and I would think you'd have to dispute the bill with the
hospital based on the documentation from the audit. Also I'd pursue this
w/ your insurance company and possibly try to find a way to get more paid.
I am so thankful I don't have to go out of network!
— [Anonymous]
August 27, 2001
while appealing your insurance to reconsider some of these charges for
payment, speak with the billing dept at the hospital and see if you can
have some of the charges reduced and make payments, sometimes they will
consider wrighting off some of the amounts due to your finanical situation.
— [Anonymous]
August 27, 2001
check web site dranonymous.com/hypernews/get/info/14/1/1.html
— [Anonymous]
August 27, 2001
Christi, I have been watching with interest your situation with your
insurance company. I also am looking at going out of network and will have
to use this hospital. From what I understand - the hospital and insurance
should come to some understanding without really involving you. You have
met your deductible and your obligation has been met. The hospital has
accepted some payment from your insurance company? I say let them battle
it out. Step away, this is between you insurance company and the hospital.
I have also spoken with the people at that hospital (rude and unfriendly,
think their relatives must work for some of the area doctors) and have come
to believe, by their attitudes and the experiences of others who have had
astronomical bills after 3-day, uncomplicated WLS at this hospital
($56,000),...that they have a racket going. Some insurances shrug it off
and pay it, some fight it and eventually have it reduced. Kind of makes
you sick to think they will purposely pad the bills of people who need help
so desperately. And I don't even want to hear from those people in
healthcare....I'M IN HEALTHCARE and know the difference in turning a profit
and gouging. And so you might wonder why I even going to consider having
surgery there....my surgeon is GOOD and my alternative is going to Spain.
Good luck,Christi...Don't freak, keep your wits about you and you might
consider calling your insurance commissioner...I am positive he'd be
interested in hearing about it all. Do it today, you'd be surprised at how
cooperative hospitals, insurance companies and doctors become after letter
from him.
— [Anonymous]
August 27, 2001
Whatever you do follow this and don't leave this in the hands of anyone
else. The hospital was out of network and they therefore DO NOT have a
contractual obligation to accept what your insurance pays as full. Talk
w/ your insurance tell them whats happening and that the hospital says you
are liable and that you need to talk w/ someone to get the two parties
together to deal this out. Good luck :(
— Dawn R.
August 27, 2001
CHECK YOUR LAWS IN THE STATE YOUR RESIDE FOR REASONABLE AND CUSTOMARY
CHARGES ALSO CHECK WITH STATE ATTORNEY GENERAL FOR ANY GUILDLINES ON
MEDICAL BILLING
— [Anonymous]
August 27, 2001
Thanks for the advice so far everyone. . . I guess it wouldn't hurt to call
the insurance commissioner. . .which one do I call though? My ins co is
based in Louisiana, my surgery was performed in MS and I reside in FL!!
LOL!! Also, I tried the DrAnonymous link by cutting and pasting and it said
it could not be found. . . I played around teh home page there but couldn't
find the page I needed. HELP! And the lady who is also considering going
out of network to this hospital. . . have we been in contact already?? My
ins told me the same as you say, that's it's really between them and the
hospital now (altho I still don't understand that if they're OON!) Email me
privately and we can chat! I TOLD the financial counselor there the same
thing when she told me I may have $20-$25K left to pay after
insurance(funny how she knew that number huh?) I told her to tell me now
and I'll pay out of pocket to go to Spain!! Why bother with ins huh??
Keep any other comments or advice coming dear people. . .I can use all the
help I can get! Blessings,
— ChristiMNB
August 28, 2001
I had a similar inncident w/ another surgery. I simply
wrote the hospital a letter stating my insurance co. is paying (amount)
and they feel this is "reasonable" ( R&C)
and I am going to pay what I should according to my insurance plan. They
accepted it and I never heard back from them. ( of course my bill wasn't
as high as yours
but it was over $1000. good luck
— [Anonymous]
Click Here to Return