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  1. #1
    momtwoboys is offline Junior Member
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    Emergency Room/Doctor Billing

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

    We have a Blue Cross/Blue Shield PPO, w/ a $1000 deductible per individual (for non-covered expenses, etc). We live in PA, the PPO is based out of Texas (my husband's company's headquarters).

    I got 3 stitches in my finger at the ER (because our doctor's office was closed over Mem. Day weekend). I paid the $75 ER copay, as well as the $92 deductible to the Hospital/ER that was left over from what our health insurance did not cover.

    Now, I am receiving an additional bill from a physician's group, supposedly from the physician (actually, physician's assistant) that treated me. The PPO is denying this bill/claim altogether, leaving me with an almost $200 bill. I have several questions regarding this bill and the legalities:

    1. Can they double-bill me (the physician's group) for services already paid through the ER and my copay. They are charging me for an ER visit ($82) and repairing the wound ($101.96). Is this allowed, since I already paid for this through the hospital?

    2. The physician's group is charging me a $16 fee for monitering my "blood oxygen level". At NO time did any doctor take blood or check my pulse. The nurse did check my temperature/blood pressure when I was being admitted w/ an ear thermometer. Why the $16 charge from the physician's group?

    3. Why does my insurance not have to cover the doctor's services? When I normally go to any doctor that is a PPO member, I am only responsible for the copay.

    I talked to the non-helpful insurance company today. They basically said I was responsible for the bill, and tried to tell me the nurse checking my temperature w/ an ear thermometer was worth the $16 charge. I was supposed to participate in a customer survey afterwards, and somehow the lady who was on the phone with me put me on hold and made it so I could not access the survery (after she stopped talking to me).

    When I had 100% coverage (no deductible) in the past through Blue Cross, the same thing happened one time. Blue Cross then told me that it was not legal for the doctor to "double bill" me and THEY refused to pay the bill. I feel as if they don't care because I have a deductible.

    Any help would be appreciated. It's not about the money, it's about what is right or wrong. It's about the insurance company's rudeness and poor customer service.

    Thank you!What is the name of your state (only U.S. law)?
  2. #2
    ecmst12 is offline Senior Member
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    It is 100% normal to get 2 bills from any service received in the hospital - one from the doctor and one from the facility. If you had xrays or labs you'd get a separate bill for those too. What I don't understand is why your insurance isn't covering it, unless they are applying it to your deductible (in which case they are correct that you owe the money).

    The blood oxygen monitor is the little doodad that fits over your finger.

    This is not a double bill. The hospital charges you for the use of their facility, the doctor charges you for his knowledge/expertise/treatment. Services in the ER are always more expensive then services provided anywhere else because of the overhead involved in providing 24/7 service.
  3. #3
    tranquility is offline Senior Member
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    If the emergency room is a participating provider, the doctor should be one too. Some ER doctors seem to bill under a non-contracted entity in what seems an attempt to get a greater amount in compensation then they would have gotten under contract as a participating provider. Is the insurance company saying they are not paying until you pay your deductible (as the doctor was not a participating provider) or what?

    If the former, explain the situation in a letter to the insurance company. They will follow up and your billing may change.
  4. #4
    momtwoboys is offline Junior Member
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    Thanks for your help! They never used the blood oxygen monitor (finger "doodad" LOL) at all! So, that charge really makes me angry. I don't care if it's only $16.

    As for the deductible. How do they determine whether or not a charge is applied to my deductible or whether they have to cover it? I did pay the $75 copay.
  5. #5
    Zigner is offline Senior Member
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    Quote Originally Posted by momtwoboys View Post
    As for the deductible. How do they determine whether or not a charge is applied to my deductible or whether they have to cover it? I did pay the $75 copay.
    It is laid out in your contract...
  6. #6
    ecmst12 is offline Senior Member
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    If you have a $1000 deductible, then the first $1000 that your insurance would pay is applied to your deductible. It doesn't count amounts over the negotiated rate or non-covered services, so if the doctor bills $100 but the amount your insurance would pay is $75 (due to the contract between your insurance company and the doctor) then $75 goes towards your deductible and the other $25 must be written off.
  7. #7
    cbg
    cbg is offline Senior Member
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    Quote Originally Posted by tranquility View Post
    If the emergency room is a participating provider, the doctor should be one too.
    Tranq, that is not necessarily the case. Although both the hospital and the insurance provider would like it if they could, neither can force every doctor to participate. ER room docs, radiologists, anesthesiologists and sometimes pathologists are notorious for refusing to join the associated networks with the hospitals they work in, believing that as they have something of a captive audience, they can make more money as non-par providers.
  8. #8
    tranquility is offline Senior Member
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    I understand the argument and agree. At the same time, even though it may be more profitable to have independent contractors rather than employees, people go to a hospital and not to the specific ER doctor. Perhaps because of this reality hospitals pressure the doctor to accept contracted payments when challenged as in my travels with this issue many times, once I have written the letter to the insurance company, it seems things work out as though they are a participating provider. In two instances, they WERE a participating provider and were subject to some kind of audit by the insurance company for their billing practices.

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