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Old 08-30-2011, 10:00 AM   #1
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Blanket Medical Payment

I just got off the phone with a hospital administrator about charges for a diagnostic test that my DW. Here are the facts.

1. DW went to a regional medical center for a routine yearly test.
2. Based on the outcome of that test, further testing using an MRI was recommeded.
3. The tests were conducted and nothing was found. My judgement at the time was that the need for the secondary testing was questionable.
4. We've received a bill from the Radiology provider for the hospital, telling us that the insurance company had rejected one of their charges and that we were responsible for it entirely.

Only now did we find out that the procedure they used was a "computer assisted diagnosis" and that it is deemed experimental by the insurance company and "has no efficacy" in the determination of medical problems.

For me the problem isn't the procedure but the fact that the hospital and the Radiology group hide it under a blanket statement that my wife had to sign, agreeing to the charges for the tests. She signed that paper for the original testing, not the MRI and there was no indication any place of experimental medicine being involved.

Following the hospital's logic, I have to sign the blanket statement to be treated and they, in turn, can chose any type of treatment without further agreement from us. My argument is that I expect them to follow standard, approved medical treatment procedures and that I need to be specifically informed and grant specific permission for anything that isn't accepted as standard medical procedure.

Thoughts?

P.S. I got stuffed with a $7,000 charge from a provider who used an experimental surgery to treat our daughter's TMJ without telling us. I'm very sensitive on this subject.
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Old 08-30-2011, 10:13 AM   #2
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If of course time allows, we always make the facility contact Blue Cross ( in our case) for pre-approval.
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Old 09-01-2011, 09:09 PM   #3
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Problem is: your wife signed the consent and while it didn't contain explicit wording about the testing it did allow them to proceed. If you considered it not required then that was the time to question what was going on, not months later.
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Old 09-01-2011, 09:38 PM   #4
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Cliff,
It seems you have two choices. Try to negotiate the bill down as low as possible and then consult an attorney about the experimental aspect of treatment. Based on what your attorney says you can weight the cost of that action to the negotiated amount of the bill. The attorney may decide you have a case and you can decide if its worth pursuing. Good luck!
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Old 09-01-2011, 10:01 PM   #5
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What we have done for a number of years was to note on the papers we complete about insurance and responsibility is...."All services are to be provided within plan benifits." The hospital has yet to question it, but when you start getting all of the auxiliary bills from DR.s for reading, consultations, etc and thay claim they are not part of the net work and do not agree to the insurance schedule of fees, I refer them to the hospital. If the hospital contracted for services from someone out of my coverage, it is there problem. The hospital had verified my coverage and knew what my plan covered. All I will pay the DR. is what ever the insurance company paid plus the 20% copay if applicable.

ER DR.s are another place that you get hit with out of plan coverages.

SO far, I win every time and my daughter uses the same tactics.

Ken
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Old 09-01-2011, 10:13 PM   #6
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ouch

I agree with adding the line about "within our coverages" it pretty much makes them at least try to get approval....
however we have tricare, and they simply dont pay CRAP
3k on a 50k surgery.
my part was 300.
because they agreed to tricare's rules and pay outs, by accepting me as a patient. IMO they lost 47k on a very costly surgery

sooooo when you get a procedure...ask and make sure they accept your insurance and its "no pay clauses"

hope it works out for you
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Old 09-01-2011, 11:00 PM   #7
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I appreciate all of the input. I'm definitely going to use the "all services to be provided within" statement on all future forms.

The plot has turned out to be even thicker. The hospital and the insurance company have a contract, too. Part of that contract is that the hospital cannot "net bill" me for rejected claims by the insurance company. They did anyway.

I got the provider's office manager to admit that no insurance plan covers the procedure that they are using and they knew that before they did it. I nearly went ballistic. I asked her how she expected that to be covered by the hospital's blanket statement and whether she thought that a judge would agree with her trying and she admitted that probably won't work either.

Today, she agreed that they never should have billed me as they did and that she was cancelling the charge. I had already deducted the charge and paid the rest that I owed so I'm square for the moment.

I'm still pursuing this matter with the hospital. Their blanket form says nothing about their contracted providers and I contend that none of them should be able to bill experimental procedures without specific notice to the patients. The hospital director understands that if I don't get a reasonable answer about this from them, I'm going to take the matter to third parties.

Thanks again for the help. I really appreciate it.

Charlie
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Old 09-02-2011, 12:08 AM   #8
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Many hospitals are using diagnostics with computer assisted diagnosis, especially mammograms. You can try going directly to the ceo or hospital administrator to get the charge removed. I like the response of writing in all services are to be provided within the plan. It is just amazing to me how hospitals are willing to take a much lower payment from medicare or private insurance, yet will not work with individuals trying to pay a high cost bill.
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Old 09-02-2011, 12:47 AM   #9
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I would call the radiologist, explain that your ins won't pay for the computer to read the mri and ask that they have a human read them and re-submit the claim.

Many a time the ins co has told me the problem is how the claim was coded. A redo is often the fix. I once had my annual well woman checkup denied because my doc included obesity as the 4th diagnosis. Re-submitted without that and it was paid.
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Old 09-06-2011, 01:39 AM   #10
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Hospitals will try and charge for everything even if it's against the law.
My step daughter was in the hospital for less than 24 hours for sever leg pain, the bill was over $17,000. They diagnosed it as gout and sent her home on a Friday. They gave her a prescription and sent her home with instructions to elevate her legs.
She died next Tuesday of blood clots that formed in her legs and lodged in her lungs.
For months they tried to collect from her "estate" which I was handling. Come to find out that they knew she was indigent and on welfare and here in WA state they are required by law to write off the bill. They tried for months to get me to pay (personally) on it, then they turned it over to collection agencies.
We never paid a cent on the bill as there was no money in her "estate". We never filed any paperwork other than the custody papers for the two grandkids (that was $6,000 in legal bills alone).
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