Reasonable & Customary

[Antigone*]

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

My daughter was involved in a major accident in May of this year. She went to Arrowhead Regional Medical Center because of the severity of the accident. I have Kaiser Permanente. To date Kaiser has been paying the bills. The full bill from Arrowhead was over 500,000. Kaiser has paid everything except 64,000.

I spoke to Kaiser and they indicated to me that they have paid according to reasonable and customary guidelines. Arrowhead is telling me that because they do not contract with Kaiser that they don't have to take what is reasonable and customary. They informed me that if I didn't pay the full amount the bill would be sent to collections.

Kaiser is telling me that it is against the law for them to "balance bill" me. Arrowhead is telling me that is not so?

Okay my forum friends, can you please shed some light on this for me? Any advice on how I should proceed?

take care, anaWhat is the name of your state (only U.S. law)?

 

[tranquility]

California statutes are unclear in your situaiton. They clearly cover when the hospital has contracted with the insurance agency, but they are uncertain when it is a non-contracted treatment or person in an emergency situation.

I believe there is litigation just started a few months ago regarding this very issue.

Info edit:
Yep, there is very specific litigation over this. After a quick Google search, I found:

http://www.ama-assn.org/amednews/2008/08/18/prsa0818.htm

 

[ecmst12]

If there is no contract between the hospital and the insurance company, then the hospital absolutely can balance bill you and you are responsible to pay.

If these services were provided in a medical emergency, then Kaiser really shouldn't be deducting ANYTHING for reasonable and customary, but should pay based on the full billed amount (whatever percentage your policy specifies). Talk to them again.

 

[tranquility]

This is the great state of California and the people's republic of California disagree with you.

Please see:

http://www.dmhc.ca.gov/library/reports/news/tpbbeffpub.pdf

The doctors will be suing, or have sued, but as of now, that's the law.

 

[Antigone*]

If there is no contract between the hospital and the insurance company, then the hospital absolutely can balance bill you and you are responsible to pay.

If these services were provided in a medical emergency, then Kaiser really shouldn't be deducting ANYTHING for reasonable and customary, but should pay based on the full billed amount (whatever percentage your policy specifies). Talk to them again.

Tranquility and Ecmst12

My thanks toboth of you. The information you have provided me will be very helpful.

take care,

 

[momm2500]

i have never heard of an insurance company cutting an actual hospital bill for reasonable and customary. with a bill that high, i am surprised an audit was not done.

 

[ecmst12]

The link is inconclusive, if you ask me. It says they have sued a provider for balance billing recently - the outcome won't be known for years, most likely.

 

[Antigone*]

i have never heard of an insurance company cutting an actual hospital bill for reasonable and customary. with a bill that high, i am surprised an audit was not done.

This was just the hosptial bill. Her surgeons were another 100k. There was about about another 15-20 in mri's, ct scans, x-rays and other procedures. Her sub-acute care is now costing about 38k a month.

We are thankful that we have insurance but we've always been told by the carrier that all costs except co-pays are covered. I do have medi-cal for her now but I'm not sure if I can submit that to them. Do any of you have any thoughts on that prior to me calling them tomorrow?

 

[ecmst12]

Depends if the Medical was in effect when that hospital bill was incurred.

 

[Antigone*]

Thanks

Tranquility,

I wanted to publicly thank you for the information you provided me and for your help with my concern. I did file a grievance with the Great State of California. They forwarded my grievance to Kaiser who called me today and informed me that the remaining balance of the bill would be paid today.