Can y’all help me sort out a crazy ER bill for my teenage daughter?

[ronmstark]

My daughter was having severe stomach pains while at college so she went to the hospital in Statesboro, GA and they ran some tests, did a CT on the spot, didn’t find anything wrong, and sent her home to follow up with her PCP. We never learned a cause and it hasn’t happened again. Later we got the bill and it was over $15,000 with our outstanding portion almost $7000. I guess the only hospital is town is not “in network” and instead is in the “savings tier” so they only covered 30% and it looks like the hospital added a $3000 adjustment (I’ll post the bill below). We’ve already called to see why it was so high and the only thing they said was if we pay it off we can get a 20% discount. $5500 is still way more money than we have. They offered a payment plan as well, but I want to try an get it reduced further first. Can you all help me figure out the itemized bill and offer some tips to get this fixed, please? Some of the the prices charged seem outrageous, 7 grand for a Ct scan not the least of which. Thanks in advance.

https://imgur.com/a/BbhjNnG

 

[sdrevcop]

@ronmstark Went through a nasty ER bill last year. First of all so sorry this can be so frustrating and show how fucked our Healthcare system is. A few tips that may or may not help your situation:

1. Check with your insurance on if this counts as an emergency. Most insurance plans if an emergency determination is made then the bill should be re run through your insurance as an in network provider.
2. If you are stuck with the big bill still set up a payment plan with the hospital. They are usually pretty flexible. No interest and low monthly payment. It will keep it in good standing and not mess up your credit.

Good luck!!!

 

[wandering_mike]

@sdrevcop Definitely want to emphasize point number one. I had a bad ER bill and my sister works in insurance and told me to make it clear it was an emergency. She could have had a burst appendix, there was no way for her to know without emergency treatment (and it’s probably why they did the CT scan).

 

[ronmstark]

@sdrevcop I’m going to check on number 1 today. Thank you.

 

[1dookie]

@ronmstark If you think the prices are elevated maybe you can ask for the CPT code and compare what is a fair price in your area for it: https://www.fairhealthconsumer.org

If its too high compared to the average you coild try and negotiate with the billing office

 

[wacs]

@1dookie Thank You for the link

 

[foreverever]

@1dookie From my experience this is in the neighborhood. My hospital charges between 7 and 8 for the same exam from what I can infer without the CPT code.

 

[baileyscave]

@ronmstark I don't think it would solve anything here, but I'm curious if you could call the insurer and ask which Hospital w/ ER is covered at the higher tier and have them search by distance.

Kinda terrible that your only local solution isn't a preferred facility.

 

[foreverever]

@ronmstark Read through everything that’s been posted so far and there’s some good stuff. I work in registration at an ER in GA so I’m not in billing but I understand enough to be dangerous. Here are three other tips:

1. Apply for financial assistance. A lot of people think it’s only for self pay but you can do it with insurance and your daughter SHOULD qualify for something because she is her own guarantor and legally they can only use HER income and assets. It’s not like financial assistance for college where they look at yours.
2. Call customer service to set up a payment plan. I know you want to wait and see what your insurance says but there’s no harm in a payment plan to make sure you keep the account in good standing while not being overwhelmed.
3. Definitely take the advice of others and follow up with your insurance company. Here in Georgia, ALL insurance must be accepted for any emergency service (ER or L&D emergent). At my hospital we even have to accept Kaiser and their fee structure if they come for an emergency. There should be NO issue with the hospital being out of network since she was not admitted. This is dictated by EMTALA which is federal and also by numerous GA state laws and other federal laws.

PLEASE NOTE: from what I’m seeing, it looks to me like her insurance did what it was supposed to with the contractual adjustment (write off) and the payment that are shown. So please do not be disappointed if the only thing you get from calling your insurance is a “sorry, we paid appropriately under your plan and this is how we would have paid at any facility.” Some insurance these days just is not that good.

 

[resjudicata]

@ronmstark You can apply for hardship. Call the hospital finance dept and ask to fill out an application.

 

[godsdaughter]

@ronmstark Also in GA. I have some friends in Newnan, GA that are still paying off the birth of their child from years ago. They are paying monthly, but only paying a little here and a little there..

The hospital encourages pay in full discounts, but you can essentially pay only what you can (ie: $10 monthly?) towards the bill and not get sent to collections. There’s likely no interest either.

 

[kittin]

@godsdaughter

The hospital encourages pay in full discounts, but you can essentially pay only what you can (ie: $10 monthly?) towards the bill and not get sent to collections. There’s likely no interest either.

This is not true. Some hospital may have that policy but as rule is if your payment is not adequate and a payment plan is not set up/ approved wity them they can still send you to collections

 

[mountaintrip98]

@ronmstark I'm confused because you say the hospital is not in-network, but they're taking a $3008.30 write-off like they are in-network. Is "Savings Tier" maybe some sort of extended network? And I take it your deductible is over $7000 for that tier?

The idea behind tiers is to try to direct people to more cost effective providers while still giving them in-network protections against balance billing and provider discounts if they don't. But you can still appeal it to be paid at the highest level of benefits due to an emergency. The company I work for would automatically bump up the tier with a dx of abdominal pain, but other companies their system doesn't do it automatically so you may need to appeal.

 

[ronmstark]

@mountaintrip98 It appears that the crux of the issue here is that the insurance only paid 60% (standard tier for non-emergency) instead of the 80% they should pay for emergency visit (maximum tier regardless of provider tier). I need to appeal to have it classified as an emergency.

 

[resjudicata]

@ronmstark The good news is, is that appears balance billing is no longer legal in GA.

The bad news is that the law is so new, I can't figure out who is supposed to enforce and make hospitals accountable for following the rule.

I suspect you need to start with these guys

maybe these guys

But I doubt it. The law reads more like it's on the hospital to accept the payment as is.

I suspect that Georgia department of consumer affairs would be your next best stop.

But I would start by calling the billing department of the hospital and asking why they're so special that this law doesn't apply to them.

 

[mountaintrip98]

@resjudicata This is not balance billing. The original total on the claim is $15.008.30, and insurance paid $5,220.00 If this were balance billing there would be no discount applied and the OP would owe $9788 instead of $6788.30.

This is not out of network, otherwise there would be balance billing and the whole $9788 would be owed. The provider is still under contract, just the benefits are much lower. I'm assuming this is an EPO type network with only select providers in the home area giving the highest level of benefits. The confusion is the phrase "in-network" is kind of ambiguous since it sometimes means "in the highest level of benefits network" and sometimes a synonym for any "contracted provider" in any level of benefits.

So the good news is the OP doesn't have to pay the $3008 discount. The bad news is that contracted providers are normally not allowed to negotiate cost sharing and need to make a good faith expert to collect it (although they are allowed to accept payments over time, just not reduce the total amount. The good news is that abdominal pain is a classic emergency so this would stand a good chance of paying at the highest level if it were appealed.

 

[ronmstark]

@mountaintrip98 They technically paid 60 percent but we still owed the $2k deductible. Based on what others have said, they should have classified it as an emergency and paid 80% so I’m going to appeal.

 

[kimsta]

@ronmstark I would also double check if you reached an out of pocket maximum. At the very least it could help with future visits.

 

[resjudicata]

@mountaintrip98 Yea, that's what I was getting around at. It's not a balance bill in the traditional sense, but insurance is still paying 20% less than it would have been a "preferred" hospitals, despite it being an emergency. And the hospital is trying to collect that 20% difference. So, it's balance billing in that respect.

 

[mountaintrip98]

@resjudicata You can use "balance billing" in colloquial, general sense, but it has a very specific meaning legally and with insurance, so it's best to stick with that when talking about insurance. The very specific meaning is the difference between the billed charge and the allowed amount for non-network providers.

Yes, Georgia law, and in most other states provides protections against that- being billed the difference between the allowed amount and billed amount in emergency situations and for things like non-network anesthesiologists at an otherwise in-network facility.

It doesn't protect against an in-network claim being paid at 60% coinsurance instead of 80% due to tiering, which is apparently the case here. It's possible there's a local law requiring emergency services to be paid at the highest level of benefits, I don't know. But that's a completely different insurance and legal concept than the strict meaning of balance billing even if the net result is still a big bill for the patient to pay.