How to solve Billing Dispute Between Insurance and Hospital

[wuliao]

What is the name of your state? New Jersey

On January 2005, my wife had an ultrasound which was authorized with the insurance company. She was pregnant and was fully insured under my name.

We had not received any bill regarding the ultrasound, until 3-4 months later. The hospital sent us a bill with 0 dollar balance. And it listed about $1200 fees waiting for the insurance company to pay.

I then called both the insurance company and the hospital. Both hospital and the insurance company agreed that it was Not our responsibility, since it was fully insured. But the hospital said the insurance company paid too little, so they are still collecting the money. And the insurance company said they have paid the amount they should pay.

And then we stopped worrying about this issue, since we thought anyway it is the dispute between the hospital and the insurance company. We have a new born baby to keep us busy. And both the hospital and the insurance company were working on it. But the hospital keep sending us the 0 dollar balance bill monthly.

Now it comes to 2006, and my company switched the insurance company. We suddenly received a denied claim from the insurance company regarding the ultrasound. But the denied amount is $300 or so. And the hospital suddenly added a message in the bill to say that it is our responsibility to collect the $1200 dollars from the insurance company.

We were pretty shocked how the disupute evolved. What would be the normal procedure to solve such dispute? Why suddenly they push the issue to the patient, even the patient was fully insured.

Your suggestions are highly appreciated.

[Job_Hunting]

Actually, the agreement is between you and your insurance company, not the insurance company and the provider or facility.

If your insurance company has not paid your bill, or paid less than what the accepted fee is, it is your responsibility as the patient as you received the services.

The hospital's billing dept, naturally, will try to collect the funds for a time as it is in their best interest to get paid; however, if they do not get results, they will default back to you, the patient and member.

All you can do at this point is call your insurance company and try to work it out with them. The hospital can and most likely will send your account for collection action if it's not paid by someone.

[wuliao]

Thanks. But the insurance company and the hospital had one year to solve the issue. And the bill was never directed to me. At least from my phone conversation with them last year, The insurance company thought they had paid the amount for the service, and the insurance company did not think I should pay any of it as well. And my wife was fully insured for the ultrasound.

I will call both the insurance company and the hospital again. But if all parties do not agree upon the amount, what should I do? Does it involve any kind of insurance fraud? Or the hospital charged too much?

[Job_Hunting]

Insurance can be very complicated. They like it that way.

If the hospital has a pricing contract with your insurance company to accept a lesser fee for services, the hospital is obligated to write off that portion of the bill.

Without all the facts, it's hard to be sure. For example, are they billing you for a true patient portion? Is this the portion that should have been written off due to contract? Is the bill actually from a non-contracted provider working within the hospital, hence leaving you a patient balance that you were not aware you'd get? (common, and most members not aware of either). Was the service not covered under your plan?

Your insurance company could have made a mistake, and maybe the hospital did. Start with the insurance company. In any event, it's still in your best interest to try to resolve it as the hospital still most likely will just send it off to collections if not resolved.

[FLMommy]

Does your insurance co send you Explanation of Benefits statements, showing what they paid, to whom, for whom, and claimno's? If you have a statement showing they paid the hospital x amount of dollars, fax it to the hospital billing department. You might also want to contact your insurance co and ask them for the check no. for the x amount of dollars they sent the hospital. It's not that hard to prove the hospital got paid - your insurance company should have a bank statement or something to show for it.

You might have to pay the 300 because the hospital is charging more than the average place does for an US. The 300 is then above customary and reasonable charges, and you are responsible to pay. Is the hospital a participating provider? Are you 100 percent covered?