Hospital is threatening me and harassing me. They released my very personal informati

[Zigner]

My feeling is that it is not the patient's "job" to verify the status of each health care provider in such a situation.

The point is that it's definitely not the hospital's job.

 

[tranquility]

The point is that it's definitely not the hospital's job.

Why would you say that? Why wouldn't it be the hospital's job to have its providers be participating providers if they are a participating provider? Or, if not, to specifically disclose the fact? Do you know how many "providers" there are in a hospital situation? There could be hundreds of different billing sections or centers on a single billing. At what point does the duty shift?

 

[Zigner]

Why would you say that? Why wouldn't it be the hospital's job to have its providers be participating providers if they are a participating provider? Or, if not, to specifically disclose the fact? Do you know how many "providers" there are in a hospital situation? There could be hundreds of different billing sections or centers on a single billing. At what point does the duty shift?

It is not the hospital's job to verify if a provider is in the network of every single insurance policy holder that they may come in contact with. In an emergency situation, the insurance company should likely be stepping up. As has been mentioned above, it's almost always (I would hate to make a full blanket statement, as there is no way that *I* could know the details of every insurance policy out there) the insurance company that will end up paying in an emergency situation.

 

[OHRoadwarrior]

I suspect the OP's problem is not that the insurance will not pay out of network. I suspect the problem was OP's additional out of network deductible was greater then the total bill. Therefore, even an "allowed" amount would be due by OP.

 

[tranquility]

It is not the hospital's job to verify if a provider is in the network of every single insurance policy holder that they may come in contact with. In an emergency situation, the insurance company should likely be stepping up. As has been mentioned above, it's almost always (I would hate to make a full blanket statement, as there is no way that *I* could know the details of every insurance policy out there) the insurance company that will end up paying in an emergency situation.

Since the hospital is a participating provider and has formed a contract with the insurance company, they are in a far better position to determine coverage than the policy holder. They don't just admit anyone into having rights there. They know everything about the providers they allow into practice inside. Part of the application includes the insurance the provider accepts.

 

[tranquility]

I suspect the OP's problem is not that the insurance will not pay out of network. I suspect the problem was OP's additional out of network deductible was greater then the total bill. Therefore, even an "allowed" amount would be due by OP.

I agree with that, but add it is still possible the doctor was not actually out of network.

 

[Zigner]

Since the hospital is a participating provider and has formed a contract with the insurance company, they are in a far better position to determine coverage than the policy holder. They don't just admit anyone into having rights there. They know everything about the providers they allow into practice inside. Part of the application includes the insurance the provider accepts.

So, the entity that has formed a contractual relationship with the insurance company is in a better position to determine coverage, right? Like, the consumer who purchases a specific product (plan) with a specific set of participating providers.


Tranq - you're off on this one. For example. My insurance plan has the same name and the same insurance cards as that of my assistant. However, he has selected a cheaper version of the plan that has a more limited selection of doctors. Yes, the doctor participates in "Blue Cross", but do they accept "Blue Cross Value Selection Optima"? (Made up examples)

This is NOT the hospital asking for the money from the OP. This is the doctor. I stand firm in my assertion that it is NOT the hospital's responsibility to confirm that the doctor is an in-network provider for the OP's specific insurance plan.

 

[justalayman]

My feeling is that it is not the patient's "job" to verify the status of each health care provider in such a situation.

The hospital was a participating provider. As the doctor comes up in the ER for the initial exam, the patient asks him, "I have Super Health insurance. Are you a participating provider?" As the phlebotomist comes up to take blood, "I am Super Health insurance, are you a participating provider?" When the blood gets taken to the lab, "Make sure the lab you send the blood too is a participating provider for Super Health!" Same for the technicians who do the xray, ct scan, mri AND the radiologists who read the films. When the nurse comes in to put a band aid on the boo boo, does he need to ask her too?

I think that all the services received at a hospital listed as a participating provider should be participating providers absent specific disclosure to the contrary. At least that is the position I've taken and won with at the lower in-company appeal processes. I've been though this situation many times during my wife's illness.

One thing (other than appeal) I think the OP should consider is if, in fact, the doctor is not a participating provider. I had this specific situation at a local ER with the difference being the ER doctor having an out-of-state billing service. Because the billing service was not a participating provider, the co-pay was 80% rather than 20%. I explained in a letter to the insurance company and pointed out the actual name of the doctor and where he practiced and the insurance company did a check and found the doctor was a participating provider AND found that because of the billing service was getting compensated (from both the patient and the insurance company amount combined) at a greater than contracted rate, the billing service owed the insurance company some money. Probably some patients too, but I was not made aware of any litigation regarding that.

but the reality is that since the phlebotomist or the doctor or any of the other "departments" involved may be a separate business entity, that is what it has come down to. While the hospital may be a participating provider, there is no obligation that any of the sub-contracted services also be participating providers and unless the insurance companies are pushed to address the issue, it will remain as it is.


the problem with attempting to put a blanket position on all those working under the hospital umbrella is:

there are many many different insurance providers. Each of them offer many many different policies that often have different lists of participating providers. Given that situation, it would be impossible for a hospital to guarantee that all of its subcontractors are also a participating provider in any given patients specific insurance plan.

again, this is an issue the insurance providers need to be pushed to address

 

[justalayman]

Why would you say that? Why wouldn't it be the hospital's job to have its providers be participating providers if they are a participating provider? Or, if not, to specifically disclose the fact? Do you know how many "providers" there are in a hospital situation? There could be hundreds of different billing sections or centers on a single billing. At what point does the duty shift?

and there can be hundreds of policies involved, each with their own list of participating providers so, not why but how could a hospital actually verify the PP status in each situation, especially since they actually have no control and often no knowledge of such a contractual situation with a sub-contractor providing services within their building?

Additionally, how would a hospital deal with a situation involving varying providers lists. Imagine this;

patient enters hospital- participating provider- no problem

er doc (separate entity) must be verified as a PP, If the one on station is not a PP, what do you do? Wait until a PP can be located or do you boot the patient?

then, blood work- again, separate entity- what if they are not a PP and they are the only blood lab the hospital uses?

X-ray services- same thing

the list goes on and on. Expecting the hospital to verify and then attempt to alter assignments, if that is even possible, such that a PP is assigned to any given patient is just beyond what could ever happen

 

[tranquility]

So, the entity that has formed a contractual relationship with the insurance company is in a better position to determine coverage, right? Like, the consumer who purchases a specific product (plan) with a specific set of participating providers.


Tranq - you're off on this one. For example. My insurance plan has the same name and the same insurance cards as that of my assistant. However, he has selected a cheaper version of the plan that has a more limited selection of doctors. Yes, the doctor participates in "Blue Cross", but do they accept "Blue Cross Value Selection Optima"? (Made up examples)

This is NOT the hospital asking for the money from the OP. This is the doctor. I stand firm in my assertion that it is NOT the hospital's responsibility to confirm that the doctor is an in-network provider for the OP's specific insurance plan.

What is the duty of a hospital as a participating provider? Is it the room? Is it the lab work? Is it the people providing service? What?

I am not off on this one. The only time service was received while in a hospital who was a participating provider where the person providing service was not paid as a participating provider was from an anesthesiologist. There was a specific disclosure and separate contract signed with that doctor before the surgery. (aka disclosure) That was in three different hospitals, so there is some comparison as to the way it is done.

I don't think you are aware at what being a participating provider means or requires from a hospital. It does not mean you signed a two page contract with an insurance company. Maybe California is different from other states and/or maybe my experience and research because of specific life changing issues on the matter only applies there. What I do know is that I won...repeatedly. The question never got to litigation as the insurance company (Funny you used the example you did ) handled things once explained properly.

Maybe it was just because I was such a pleasant person the providers gave up on tens of thousands of valid charges. Or, maybe the insurance company put the screws to them in other ways.

 

[justalayman]

tranquility;3204154]What is the duty of a hospital as a participating provider? Is it the room? Is it the lab work? Is it the people providing service? What?

it is whatever services they provide. That may be just the room. It may be supporting staff such as nurses. It may be nothing more than the room or it could be 100% inclusive of all services.

I am not off on this one. The only time service was received while in a hospital who was a participating provider where the person providing service was not paid as a participating provider was from an anesthesiologist. There was a specific disclosure and separate contract signed with that doctor before the surgery. (aka disclosure) That was in three different hospitals, so there is some comparison as to the way it is done.

it's not a matter of recieving services from a non-participating provider that is the point. It is recieving services from a provider that may or may not be a participating provider. While I think the system sucks as it is, it really is such that it is impossible to go to a hospital and be assured that all entities involved will be a participating provider.

 

[linkavb]

I see many have sided with the hospital...

But... if I am (the patient) decided to go to xyz hospital for my choice who is clearly listed as my IN-NETWORK provider, I was expected to be covered 100% by my insurance co at that time since I had met my deductible for that year. If I had known that I'd be services by out of network doctor, I would've refused to receive his services.

Furthermore, with my recent visit to the hospital, I'd asked attending nurse to send us a doctor who's in our insurance network. She replied "ALL doctors who work at our hospital are in your insurance network" I told her my experience and she said she's never heard of a hospital employing a doctor especially in ER as an independent doctor and then charge the patient non discounted fee.

I will continue to "bark" at that tree because I believe I wasn't fairly served and the hospital placed me in financial strains. Now they've attached a barking dog at me who refuses to say of the phone what's she calling about yet she wants me to give out my first born's child name to some stranger that I've never met nor know over the phone in God knows what settings and who's been chewing gum when she was speaking with me.

 

[cbg]

Alrighty then.

 

[justalayman]

I am not off on this one. The only time service was received while in a hospital who was a participating provider where the person providing service was not paid as a participating provider was from an anesthesiologist. There was a specific disclosure and separate contract signed with that doctor before the surgery. (aka disclosure) That was in three different hospitals, so there is some comparison as to the way it is done.
.

I think California may have you spoiled. When I go to a hospital, the forms signed say something like:


we (the hospital) contract for services with 3rd party providers. They separate entities and will bill you separately from any billing by the hospital. They may or may not be covered under your insurance. It is your obligation to ensure the coverage your policy provides

Just went back and checked and:

Oh Hell! OP is in Indiana. Trust me on this; what happened to OP can happen to OP regardless what California may or may not do. I'm not in Indiana but if you give me a bicycle and 5 minutes, I can be.

 

[justalayman]

linkavb;3204159]I see many have sided with the hospital...

nobody is siding with anybody. They are simply stating facts.

But... if I am (the patient) decided to go to xyz hospital for my choice who is clearly listed as my IN-NETWORK provider, I was expected to be covered 100% by my insurance co at that time since I had met my deductible for that year.

I can't recall if it was on Saturday Night Live or Mad TV but there was a regular skit where some not so pretty couple ended up together through some dating services. The skit was called; Lowered Expectations. It was meant to express the realities if life. I think it's time for your episode.

If I had known that I'd be services by out of network doctor, I would've refused to receive his services.

but did you ask if he was in network?

Furthermore, with my recent visit to the hospital, I'd asked attending nurse to send us a doctor who's in our insurance network. She replied "ALL doctors who work at our hospital are in your insurance network" I told her my experience and she said she's never heard of a hospital employing a doctor especially in ER as an independent doctor and then charge the patient non discounted fee.

well, that nurse needs to get out more. I can send you to some hospitals where it does happen.

I will continue to "bark" at that tree because I believe I wasn't fairly served and the hospital placed me in financial strains.

actually, this is an issue you have with your insurance provider.
You are personally liable for any debt incurred due to your visit. Your insurance provider has agreed, with you, to indemnify you per your contract. If they have refused to do so, it is an issue to be resolved with your insurance provider. If they can properly deny the claim, then it is as simple as the debt is yours to pay.

Now they've attached a barking dog at me who refuses to say of the phone what's she calling about yet she wants me to give out my first born's child name to some stranger that I've never met nor know over the phone in God knows what settings and who's been chewing gum when she was speaking with me.

so, for some reason a bill collector cannot chew gum or eat while they talk to you? While it is not typically seen as "professional" I really do not see why it would be an issue to make a point about either.