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Health Insurance-Hospital error in filing claim

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Account4it

Guest
What is the name of your state? What is the name of your state? What is the name of your state? VA
My mother was sent to the emergency room and later admitted to the hospital, where she spent several days. When she arrived, she did not know who she was, where she was, or what was happening to her. She was very sick. She had fallen a couple of days earlier and fractured three vertebre in her back, but did not find this out until several weeks later. They did not admit her for that, They just give her some pain medication and sent her home. While she was in the hospital they run several tests to find out what the problem was. Keep in mind, she did not know anything or anyone until the next evening. Anyway, since she has been out of the hospital, she has been getting a bill from the hospital. They have been calling her and sending threatening letters, stating that they would garnish her wages, even summons her to court if she did not pay this bill. My mother is a retired teacher from NC. She lives on a fixed income and she does not own her own home. She has state employees health insurance. The insurance was to pay at least 80% of this bill, if the hospital would of filed it correctly. Out of a $15K bill, the insurance paid less than $2K. The hospital claims that my mother is reasponsible for the rest. The insurance company tells her if they would have filed it correctly, they would have paid much more, but now it's too late. They are not willing to pay any more, because the hospital would not refile it correctly. Can this be done legally? What should I do? My mother is not in good health, and she does not need all of this stress. Please Respond.
 


A

Account4it

Guest
They did not list all the tests that were performed as necessary in order to come to a diaagnosis. They thought her symptoms could be coming from any number of things, so they did many tests to confirm their findings. I feel that all tests that they felt were necessary at that time should be listed that way when filing on her insurance. Am I Wrong?
 

lkc15507

Member
Account4it said:
They did not list all the tests that were performed as necessary in order to come to a diaagnosis. They thought her symptoms could be coming from any number of things, so they did many tests to confirm their findings. I feel that all tests that they felt were necessary at that time should be listed that way when filing on her insurance. Am I Wrong?
Account4it:

I am unsure of what this post means. Did the provider fail to bill ("list") all the tests when submitted to the insurer, or does the insurer consider the "list" of tests as not "medically necessary" to the ultimate diagnosis?

Find an Explanation of Benefits (EOB) form from the insurer and quote it exactly. Given what you say the insurer's response was, I wonder if the provider submitted proper diagnosis codes to cover the testing they provided. If your mother is still within the timely filing limits of her health plan, read the appeals process in the plan document and then submit an appeal to the insurer. If she is near the end of the appeal period, submit an appeal--anything--quickly. If she has time to appeal the insurer's decision, investigate this further. Try to find the exact cause of the denial. If the insurer denied based on "medical necessity", have the provider submit a "letter of medical necessity" for the services rendered.

If the provider failed to bill, have them do so immediately.

Best to you,
lkc15507
 

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