I'm not sure where to post this, but hopefully you all will know.....

[Petie1104]

I'm posting this with concern for a friend...

Background, we'll call my friend A, her dd and her ex....

DD was visiting ex when she got sick.  Ex took DD to ther ER and the hospital called A for her insurance information.  A gave them all the information but they were unwilling to tell A what was going on with DD.  A finally got Ex to explain some of it, but A never got any kind of forms for aftercare or follow up or anything.  This was at the end of dec. Fast forward to about a week later.  A got a call from the hospital that they didn't have all of her insurance information, so she went over it with them again.  Fast forward to now, A just got a bill from the hospital for over $2000.  The bill didn't include a breakdown of services given to dd nor did it state that they had sent the bill to the insurance company first.  A is calling the hospital later today but isn't sure what she is going to do about this bill.  I reassured A that it is probably a mix up, wrong information taken down for the insurance or something that caused this mix-up.  The question is, this bill was sent to A's parents, not her address, and the bill was due yesterday.  Is there a reason that any insurance would refuse to pay for services at an ER?  Is there something that A and I are missing?  Hopefully this turns out to be a complete mix-up that can be handled quickly, but A doesn't have the money for the bill, nor does she have the money for a lawyer if this goes to the hospital's legal department.  What exactly is A supposed to do if the insurance has refused to pay?   Should A's ex be responsible since he took dd to the ER?  There is no specifics in the CO about who is responsible for health care bills.  The reason that A has insurance on dd is because it is through the state and she has custody of dd.  Apparently, whatever the reason that dd went to the ER she has been fine since she has been home and since ex refused to give A information or any forms from the ER, dd's PCM has no clue what to do, or what the issue was or whether a follow up appt. was even requested by the ER doc. 

HELP!!  Please tell me there is a logical explanation for why A is getting billed for this. 

[hopefulfaith]

The first thing I would do is to go to the hospital and request a copy of the ED medical record.  They are allowed to charge you for copying, etc., but I would familiarize myself with exactly what happened re: the ED visit so that I have a leg to stand on when I'm discussing it with the insurance company.  Knowing the who/what/when/where/why is very helpful when you're dealing with an insurance company.

Second, I would request the billing department at the hospital to provide me with a list of charges in an itemized bill so that I know what I'm looking at.

Third, I would read my insurance company's Service Benefit Plan (or whatever they happen to call it:  it's the book they send you every year that tells you what you coverage pays for and does not pay for).  Make sure the dd is, indeed, covered for whatever they went to the ED for.

Fourth and last, remember that if the hospital did not have the correct information given to them by the child's father, then they can't bill correctly.  If the hospital thinks that XYZ Company is the insurer and that this is the policy number and that this is the demographic information for the child, then that's what they're sending to XYZ Company.  If XYZ denies the claim because of "insufficient information" (e.g., the child's SSN or whatever wasn't provided or was provided incorrectly) - which they do have the right to do ..... it is now up to your friend to ask the hospital to resubmit the claim with the correct information.  Usually, if you're pleasant about this, they'll totally do this for you because frankly, they want to get paid.

Find out why the insurance company is denying the claim --- it could be something as completely simple as the claim being filed incorrectly or incompletely by the hospital (i.e., they accidentally left off the contractual provider number for the ED physician, etc.), which is very easy to fix and resubmit.

I can't address re: who is supposed to pay as far as post-divorce agreements go, but as a former HMO nurse reviewer....here's a place to start.  :)  Good luck.  Tell her not to freak out until she figures out why exactly it's not being paid.

ETA:  She doesn't need a lawyer right now; she just needs to figure out what went on and whether the claim was submitted appropriately.  If the child has insurance through the state, the state generally pays for true emergency claims.

[Petie1104]

Originally Posted by hopefulfaith 

The first thing I would do is to go to the hospital and request a copy of the ED medical record.  They are allowed to charge you for copying, etc., but I would familiarize myself with exactly what happened re: the ED visit so that I have a leg to stand on when I'm discussing it with the insurance company.  Knowing the who/what/when/where/why is very helpful when you're dealing with an insurance company.

Second, I would request the billing department at the hospital to provide me with a list of charges in an itemized bill so that I know what I'm looking at.

Third, I would read my insurance company's Service Benefit Plan (or whatever they happen to call it:  it's the book they send you every year that tells you what you coverage pays for and does not pay for).  Make sure the dd is, indeed, covered for whatever they went to the ED for.

Fourth and last, remember that if the hospital did not have the correct information given to them by the child's father, then they can't bill correctly.  If the hospital thinks that XYZ Company is the insurer and that this is the policy number and that this is the demographic information for the child, then that's what they're sending to XYZ Company.  If XYZ denies the claim because of "insufficient information" (e.g., the child's SSN or whatever wasn't provided or was provided incorrectly) - which they do have the right to do ..... it is now up to your friend to ask the hospital to resubmit the claim with the correct information.  Usually, if you're pleasant about this, they'll totally do this for you because frankly, they want to get paid.

Find out why the insurance company is denying the claim --- it could be something as completely simple as the claim being filed incorrectly or incompletely by the hospital (i.e., they accidentally left off the contractual provider number for the ED physician, etc.), which is very easy to fix and resubmit.

I can't address re: who is supposed to pay as far as post-divorce agreements go, but as a former HMO nurse reviewer....here's a place to start.  :)  Good luck.  Tell her not to freak out until she figures out why exactly it's not being paid.

THANK YOU!!  I actually just texted her and she said that one thing that stood out was the ex misspelled dd's name.  So maybe that's what this whole mess is about.  I'm going to forward her your post though. 

[honeybunmom]

I second checking the Sevice Benefit Plan . . . but, I'd also be looking specifically for emergency room visit coverage depending on the hospital.  If the hospital that dd was taken to was out of network (assuming that is an issue for the type of plan your friend has), the insurance company may require a call prior to going to any out of network hospital.  I know it sounds silly since if one has an emergency, the last thing they're likely to be thinking about is whether they can actually go to the ER, but, it was in a plan I had in the past.

[Petie1104]

Ok, so she called, and found out it was a clerical error and she does not owe them a couple thousand dollars. YEAH!!!