Hospital billed 12k, insurance says it should be 4k. I’m left with the difference. How is this allowed?

[kbirchtree]

My billing situation is a nightmare. For a $12,000 out of network charge the insurance company is claiming the Medicaid rate is $4,400 and that is all they will pay. That would be fine with me if they negotiate that with the hospital but they didn’t. The line in the sand was drawn with me and I have to pay the difference. What good is insurance if they arbitrarily decide what should’ve been billed.

Of that $4,400 they claimed billable I’m paying $3,000 for the deductible and $722 in coinsurance. They are paying $722 total. I didn’t realize they could just decide what they want to pay. They just conveniently omitted $8,000 from the equation because they didn’t want to count it. Is this legal???

 

[pdg90601]

@kbirchtree Yes. This is why going to out-of-network providers is bad. Your insurance does not have to negotiate with the hospital, and the hospital does not have to negotiate with the insurance.

 

[shopteach]

@kbirchtree Out of network charges are the patient responsibility. Your insurance will not negotiate this for you, at least IME

 

[boseven]

@shopteach But the individual can and ALWAYS SHOULD.

It usually yields results.

 

[shopteach]

@boseven Absolutely

 

[wendyr]

@kbirchtree Call the hospital and negotiate the rate yourself, ask what the cash rate is for someone paying out of pocket. You’ll be surprised at the difference. Worst case scenario wait until December, call the hospital and they may accept a lower rate to get the charges off their books before the new year.

 

[ngocvncom]

@kbirchtree This is why you should be going to in-network hospitals. Those are the ones who the insurance company has negotiated with and who have agreed to take your insurance company’s payment as payment in full and not bill you beyond that. Your out of network hospital has not agreed to this. You are responsible for the balance bill, that’s completely normal and legal and outlined clearly in your insurance contract.

 

[kbirchtree]

@ngocvncom It was an emergency visit with a transfer I had no choice.

 

[psalm91girl]

@kbirchtree There’s no out of network for ER level visits. We’re you transferred to an in-network or out of network facility? Once the ER stabilizes you, if you’re transferred to the floor or another hospital that is out of network, then you can be balance billed. Hospitals stay out of network for this reason. Tell them you will pay x over what insurance paid, whatever you’re comfortable with, or tell them you’ll pay nothing additional.

 

[kbirchtree]

@psalm91girl I was transferred from the ER to
psych against my will. I had no choice of where I was going

 

[psalm91girl]

@kbirchtree Unfortunately, doesn’t matter if it was against your will. Many psych facilities tend to be out of network which makes matters worse. You can ask for financial assistance programs at both facilities, but at the end of the day you can either pay all, some, or none. If it were me I’d look into any financial assistance, otherwise I’d try and negotiate a bit higher than what insurance paid since Medicaid rates are minimum vs commercial insurance. Depends on your resources and comfort level, and also ask about payment plan, etc. remember the hospital would rather have something over nothing, so they usually are negotiable.

 

[heavymetaldude]

@kbirchtree If this was an emergency it is illegal to "balance bill"

Look up "no surprise billing act"

Also, does your insurance provider offer a service to negotiate rates? Sometimes they do, it's worth using them. If not, DM me and I can share the one my insurance used maybe you can hire them privately for some small fee.

 

[euroboy26]

@heavymetaldude Surprisingly it doesn’t cover ground ambulances if that was the case.

https://www.commonwealthfund.org/blog/2021/protecting-consumers-surprise-ambulance-bills#:~:text=The%20recently%20enacted%20No%20Surprises,bill%2C%20with%20bills%20averaging%20%24450.