ER visit "exceeds usual & customary allowance"

[avanny]

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

I was badly injured and had to be airlifted to an emergency room, had a CT-scan of my head & pelvis, which were pretty benign & x-rays of my foot & hand, which were then splinted. I was later released that night w/ nonlife-threatening injuries.

My insurance is a PPO through my school, which covers 100% of ER visits minus a $50 copay. However, I received a bill from the hospital stating that I owe nearly $2000. When I called my insurance, they said that since the hospital was not in contract w/ them, the hospital could charge what it wanted, which my insurance decided was not a reasonable & customary rate, and so they paid only so much.

I explained this to the hospital, and they told me I needed a copy of something stating that I did not have to pay that amount. The insurance said it was the Explanation of Benefits, which just shows "patient's liability" (~$2000) & codes for "charges exceed usual & customary allowance". With previous bills, there was also a code explaining that I was not liable to pay certain amounts, which I'm guessing is because of the contract with that specific hospital.

Now, I'm not sure what do to. I'm confused as to what the hospital actually wants so they can decrease or remove my bill. I'm a full-time student at a professional school, "working" w/out pay 60+ weekly, w/ only 1 day off per week, and surviving off loans, month to month. I don't know how I'm gonna pay this bill.

Any help or suggestions?

 

[ElvinMelvin]

What is the name of your state (only U.S. law)? CAI'm confused as to what the hospital actually wants so they can decrease or remove my bill.

The hospital wants $2000 for services rendered. They don't particularly care whether you pay it or your insurance pays it, but that's what they want.

You got treated and racked up a bill of $2K(let's assume that there is no funny business with the charges). The hospital submitted a claim to your insurance and your insurance has denied the claim, so the hospital sent the bill to you.

As far as whether the insurance company is within its rights to deny the claim depends on what your policy says. Read your policy and see if the denial is valid.

You can fight with your insurance company, but bottom line it is you who is responsible for the bill. If the hospital does not get paid in a timely fashion they can initiate a collections process against you.

Your choices are:

1) accept that your ins. co. is not going to pay and pay the bill yourself
2) pay the bill and fight with your insurance carrier for reimbursement.
3) make the hospital wait while you fight with your insurance and hope they do not start collections proceedings and ding your credit
4) Blow the bill off (really bad idea)

 

[ecmst12]

Most of the time, for emergency services from a non-participating hospital, the insurance will pay 100% of the BILLED charges after the copay, regardless of U&C. This is because since it was an emergency, you did not have an option of where to go as you are supposed to go to the nearest hospital in a medical emergency. If you are transported by ambulance, you may ACTUALLY have no choice where to go. But you will have to read your policy to see if this is the way YOUR policy operates. If it is not, unfortunately you will have to pay the bill, unless the hospital agrees to discount it for you for some reason.