Challenging bill under "usual, customary, and reasonable"

[JohnT66]

What is the name of your state (only U.S. law)? Texas

This is all in Texas.

I went to the ER with insurance. However the emergency insurance had various caps and deductibles and I am left with about $7,000 in bills. I have attempted to negotiate with the hospital, but they won't budge. I have researched the procedures, tests, etc that the hospital charged and have found them to be many times the Medicare rate and considerably more than the medical blue book rate for the same services in my area. I would like to pay the bill, and have offered to pay a number above but closer to what the medical blue book site suggests and have been rebuffed. I'm sure various users will have opinions on my situation, however I ask that commentary be restricted to my specific legal question:

My understanding is that if we do not reach an agreement that the hospital will (have the option to) sue me for breach of contract under the "sworn accounts" procedure (TRCP 185). My understanding is that an element of establishing a "sworn accounts" case is that the (in the absence of a written agreement on price) prices are to be "usual, customary, and reasonable." My question is can you point me to case law interpretation of these terms? Specifically, to what extent can I challenge the claim on these grounds? Would this question be left for the jury to deiced (or be decided by the judge as a matter of procedure early in the trial)?

More informally: Consider the following: I make the hospital an offer which seems to be the range of what other hospitals are charging in the area for the same service (which I can make a documented case for), and they decline it and sue me. If I try to proceed under the position that I received the services, acknowledge I should pay for them, but disagree that the prices are reasonable and customary, what is likely to happen in the case? If i did go this root would I be able to discovery documentation regarding price practices, etc?

To the extent possible please point to specific examples, case law, procedures, etc.

Thank You.
(PS. Yes, I know I might want to talk to a lawyer.)

 

[racer72]

Do you try to negotiate the price of groceries at the grocery store?

 

[garrula lingua]

What is the name of your state (only U.S. law)? Texas

This is all in Texas.

I went to the ER with insurance. However the emergency insurance had various caps and deductibles and I am left with about $7,000 in bills. I have attempted to negotiate with the hospital, but they won't budge. I have researched the procedures, tests, etc that the hospital charged and have found them to be many times the Medicare rate and considerably more than the medical blue book rate for the same services in my area. I would like to pay the bill, and have offered to pay a number above but closer to what the medical blue book site suggests and have been rebuffed. I'm sure various users will have opinions on my situation, however I ask that commentary be restricted to my specific legal question:

My understanding is that if we do not reach an agreement that the hospital will (have the option to) sue me for breach of contract under the "sworn accounts" procedure (TRCP 185). My understanding is that an element of establishing a "sworn accounts" case is that the (in the absence of a written agreement on price) prices are to be "usual, customary, and reasonable." My question is can you point me to case law interpretation of these terms? Specifically, to what extent can I challenge the claim on these grounds? Would this question be left for the jury to deiced (or be decided by the judge as a matter of procedure early in the trial)?

More informally: Consider the following: I make the hospital an offer which seems to be the range of what other hospitals are charging in the area for the same service (which I can make a documented case for), and they decline it and sue me. If I try to proceed under the position that I received the services, acknowledge I should pay for them, but disagree that the prices are reasonable and customary, what is likely to happen in the case? If i did go this root would I be able to discovery documentation regarding price practices, etc?

To the extent possible please point to specific examples, case law, procedures, etc.

Thank You.
(PS. Yes, I know I might want to talk to a lawyer.)

It's worth a try.
If you're under 10,000, then you can file in small claims/JP court. That gives you the option of an appeal to County Court at Law if you lose.
JP courts can be wild cards, and there are many Judges who have severe problems with Insurance cos. & hospitals. (JPs don't have to be lawyers).

You sound articulate and you're on the right path with your research.
Many Judges will 'split the baby' on emotional (& rational) cases ... maybe s/he would find for the hospital, but reduce the amount owed - which is what you want.
You're only out the filing fee if you lose, and you'll have struck a blow at, and helped expose the draconian billing practices of hospitals and insurance companies.

In JP Court, they'd probably fall over if you come in with citations to caselaw, but it's worth doing. CCL is different - they are usually proficient with the law and you will need citations.

I don't know if this could squeeze into an attack by you (counter-suit) under the Tx Deceptive Trade Practices Act. I haven't read that laundry list in a while...

If I see any relevant citations, I'll post back.
Good luck to you.

 

[ajkroy]

If your balance has been applied to the deductible, then it has already been negotiated on your behalf. To pay less than the amount applied to deductible would be a violation of your contract with your insurance and could result in policy termination, particularly if those charges satisfied said deductible and insurer paid any subsequent claims.

That isn't being frugal -- it's insurance fraud.

 

[JohnT66]

Do you try to negotiate the price of groceries at the grocery store?

...and you paid sticker price for your car, right?

 

[JohnT66]

It's worth a try.
If you're under 10,000, then you can file in small claims/JP court. That gives you the option of an appeal to County Court at Law if you lose.
JP courts can be wild cards, and there are many Judges who have severe problems with Insurance cos. & hospitals. (JPs don't have to be lawyers).

You sound articulate and you're on the right path with your research.
Many Judges will 'split the baby' on emotional (& rational) cases ... maybe s/he would find for the hospital, but reduce the amount owed - which is what you want.
You're only out the filing fee if you lose, and you'll have struck a blow at, and helped expose the draconian billing practices of hospitals and insurance companies.

In JP Court, they'd probably fall over if you come in with citations to caselaw, but it's worth doing. CCL is different - they are usually proficient with the law and you will need citations.

I don't know if this could squeeze into an attack by you (counter-suit) under the Tx Deceptive Trade Practices Act. I haven't read that laundry list in a while...

If I see any relevant citations, I'll post back.
Good luck to you.

Thank you for your (thoughtful) response.

You seem to be suggesting that I can initiate the process by filing in JP/small claims court. How would that work? My argument is that if they sue me they need to establish "usual, customary, and reasonable" which (hopefully) I can contest. Is there a way into turning this into an proactive action where I initiate the small claims filing? My worry is that if I do that, they might not have the burden of proving that the price is reasonable? Also, my understanding is that I can only sue for monetary damages here, so I assume I would need to pay the bill first. (On the other hand if they sue me will they need to do it in Small claims/JP court? If they don't can I have it moved there?)

Thanks!