medical balance billing after ER

[Lena Tokar]

I am from New Jersey
My story: fell while rollerblading in the park, was brought to a nearest hospital, staff doctor decided to call a plastic surgeon to stitch up the wound on my leg. I did not give any consent.
Surgeon turned out to be non-par with my insurance. Billed $7, 568.00 and insurance paid $4,200.00 - 100% of customary and usual charges in our geographic area and declined any additional payments.
Surgeon threatens to send my account to Collection for remaining balance.
I feel being taken as a hostage.
I did not choose this surgeon, I did not negotiate his fees, I signed some forms only 10 days later coming for a dressing change to his office ( I called 8 doctors from my network and they all told me to see whoever performed the surgery ).
What is my legal standing in this situation?
Should I go to the court?
His manager asked me to start paying and than she can ask doctor to give some discount. But my friends warned me against that.
I've read that California last year outlawed this type of medical balance billing after ER service. I live in NJ.What is the name of your state (only U.S. law)?What is the name of your state (only U.S. law)?What is the name of your state (only U.S. law)?What is the name of your state (only U.S. law)?

 

[ecmst12]

If your insurance doesn't pay 100% of billed charges even in an emergency situation, then you are responsible for the bill. If you can negotiate a discount, that is your best bet.

 

[longsally111]

I am from New Jersey
My story: fell while rollerblading in the park, was brought to a nearest hospital, staff doctor decided to call a plastic surgeon to stitch up the wound on my leg. I did not give any consent.

yes you did and I do not believe that plastics was called in without a discussion with you. You are not being truthful.

Surgeon turned out to be non-par with my insurance. Billed $7, 568.00 and insurance paid $4,200.00 - 100% of customary and usual charges in our geographic area and declined any additional payments.

ok, so far, no problems

Surgeon threatens to send my account to Collection for remaining balance.
he rendered services and you have not paid up....you owe him so.....

I feel being taken as a hostage.

excuse me? That would be if they didnt fix your leg without you paying first!!!

I did not choose this surgeon, I did not negotiate his fees, I signed some forms only 10 days later coming for a dressing change to his office ( I called 8 doctors from my network and they all told me to see whoever performed the surgery ).

no one chooses their er dr and negotiates ER charges, they are what they are.

What is my legal standing in this situation?

you signed a consent for treatment when you entered the er. You owe.

Should I go to the court?

only if you want to look like an idiot.

His manager asked me to start paying and than she can ask doctor to give some discount. But my friends warned me against that.

so you refused the payment plan they offered you....yeah....that will look good in court.

I've read that California last year outlawed this type of medical balance billing after ER service. I live in NJ.What is the name of your state (only U.S. law)?What is the name of your state (only U.S. law)?What is the name of your state (only U.S. law)?What is the name of your state (only U.S. law)?[/QUOTE]

You have no idea what you are talking about and your friend gave you bad advice. It will go on your credit and you will regret it!!!!

 

[cosine]

yes you did and I do not believe that plastics was called in without a discussion with you. You are not being truthful.

I'm curious how you came to know this. Were you present at the time? Or did you have a bug in the room?

Clearly the OP didn't handle the situation properly, and doesn't understand how this kind of thing plays out.

 

[AlexanderV]

Lena,
The thing that the surgeon is trying to do to you is called BALANCE BILLING and in most cases it’s ILLEGAL in New Jersey. In case of emergency you may ONLY have to pay a deductible / coinsurance or a copay amount according to your plan. Not a penny more! Medical providers and insurance people are trying to do everything to prevent us patients from knowing this. It usually helps to let them know that you understand your rights.

If are not a doctor you might not see the difference between a “plastic” (did you mean cosmetic?) and any other type of surgery. They should have explained it to you. Stitching up the wound could have been just a standard procedure in case of emergency. And of course they should have told you how much it would be going to cost YOU. If they didn’t it was a clear violation of your rights as a patient.

Don’t be afraid to go to the court. Let THEM look like idiots when you tell the jury that you were in pain and they offered you an expensive out-of-pocket cosmetic surgery instead of just doing what they had to do in emergency.

Read this article first: (Business Week: Medical Bills You Shouldn’t Pay):

[highlight]www.businessweek.com/magazine/content/08_36/b4098040915634.htm[/highlight]

(Just copy and paste the highlighted text into your brouser. Links apparently don't work in this forum)

Some legal references you can find here:

[highlight]www.msahq.org/Balance%20Billing%20Prohibition%20Comparison%20Chart2.doc[/highlight]

For the most recent updates on this issue you can go to:

[highlight]www.passionforsubro.com/claims-procedures/balance-billing-update/[/highlight]

or

[highlight]www.healthcareneutraladrblog.com/2009/01/articles/managed-care-payment-and-cover/balance-billing-for-healthcare-services-who-will-be-left-holding-the-bag/[/highlight]

or just Google “balance billing new jersey”. And do not forget about the Patient’s Bill of Rights: [highlight]www.state.nj.us/lps/ca/bme/statreg/patientrights.htm[/highlight]

You can always file a complaint with the New Jersey Board of Medical Examiners online. But considering the amount of your bill it absolutely makes sense to seek a legal advice from a lawyer. There are a lot of nuances in the law (elective vs. emergency procedures, usual and customary vs. allowed charges etc.) that you have to take into consideration.

Be prepared to fight. The doctor’s office will most likely be threatening you and try to ruin your credit. But you have to know that if you go to the court and win the doctor will have to pay not only your legal fees but to compensate all damages done to your credit. If you are not up to the fight it may make sense to reach a settlement with your doctor. Anyway it’s wise to consult a lawyer. There are some out there who can help you settle for a fraction of your bill. Read this:

[highlight]www.msnbc.msn.com/id/32484021/[/highlight]

In the meantime try to recall all the details. Did you sign any papers at all in the ER, if yes – was there a “Consent to Treatment” form and were you made aware of the possible fees; were you given an option to choose an in-network provider, and what is your insurance policy coverage for an out-of-network specialist (how much coinsurance you have to pay for such services). Again, consulting with an attorney specializing in medical field would be a wise choice, indeed. Don’t give up.

Good luck!

 

[ajkroy]

AlexanderV, you have no idea what you are talking about. Balance-billing out of network isn't illegal anywhere. If that were true, then people would purchase the cheapest plan available that only has one provider and obtain services all over town.

Insurance companies negotiate rates on behalf of their clients, and those negotiations hold if the client follows a certain set of "rules" (such as seeing only in-network providers). In an emergency situation, however, those rules cannot always be followed. If you are in a true emergency situation, you rarely have the time or the inclination to seek out a provider who is covered in your plan BECAUSE IT IS AN EMERGENCY!

You chose the hospital in which to seek treatment. You chose to go the ED. Your choice of providers was limited by your previous choices, and you must pay for those choices.

Look at it this way: the specialist who sutured your knee performed a service and should be paid. He/she was there for you and took care of you without demanding payment first based on your promise to pay (in paperwork signed upon reaching the hospital). How fair is it to renege on that now?

In my experience, plastics are only called in for sutures on if there is a significant concern for scarring. Did you ask for a specialist? Most any provider in the ED could have performed the sutures for you.

 

[lealea1005]

I agree with everything ajkroy stated.

In addition, perhaps the ED Physician took a look at your laceration and decided it was best for a Plastic Surgeon to suture it. Depite Alexander's assertion that "Stitching up the wound could have been just a standard procedure", he is w-r-o-n-g! The characteristics of the laceration (jagged edge vs clean edge, length and depth, potential for scarring, among other things) will dictate the necessity of a sub-specialist being called in.

When you entered the ER, you signed a release giving the ER Docs permission to treat in any way they deem necessary. He obviously felt it necessary to bring in a sub-specialist.

Longsally is also correct. It would be highly unusual if you weren't informed that they were bringing in the Plastic Surgeon to suture the laceration. Perhaps you do not remember because there may have been a lot going on...blood, pain, commotion in the ER that particular evening, etc.

 

[longsally111]

I'm curious how you came to know this. Were you present at the time? Or did you have a bug in the room?

Clearly the OP didn't handle the situation properly, and doesn't understand how this kind of thing plays out.

I come to know this because Plastics are not staffed in the ER, they are specialists who rotate doing call and have to be called in for specialty cases. No bugs here except you.

 

[cosine]

I come to know this because Plastics are not staffed in the ER, they are specialists who rotate doing call and have to be called in for specialty cases. No bugs here except you.

The OP claims he had no discussion with plastic surgeon. You claim the OP is not being truthful. I might believe you if you showed some foundation for your assertion. You did not. Therefore I will lean to believe the OP until some additional evidence suggests otherwise. So far it's one person's word against the other. I tend to believe the one that was there.

 

[ecmst12]

Longsally is an ER nurse. She knows more then you about how ERs work.

 

[dfromnyli]

Just get an insurance policy with better out of network coverage. If that kind of plan is outside of your means financially then I do not know what to tell you other then that just sucks.

 

[AlexanderV]

AlexanderV, you have no idea what you are talking about. Balance-billing out of network isn't illegal anywhere.

ajkroy, your information is outdated. Apparently, you didn’t find time to check up on those links I posted. There are some circumstances when New Jersey Administrative Law and the appropriate NJ Department of Banking and Insurance rulings explicitly prohibit out-of-network balance billing. And emergency is indeed the case.

Another question is who is responsible for the appropriate payment for the doctor’s services. Well, it is not always the doctor who has to wright-off the balance. In the case below (New Jersey vs. Aetna) the insurance company was forced to pay the difference:

[highlight]http://www.state.nj.us/dobi/pressreleases/pr070725_ordera07_59.pdf[/highlight]

Consider two different situations. There are some (usually very good) doctors who do not accept any insurance at all. They bill their patients directly. The patient pays the bill first and then submits it to the insurance company for reimbursement. In this case the patient’s out-of-pocket expenses will most likely be much bigger - not just the deductible / coinsurance but also the difference between the billed and allowed charges. On the other hand such doctor takes the risk of a non-payment and possible huge collection write-offs.

Other doctors do so-called “courtesy billing” when a patient signs up an authorization for a doctor to receive a payment directly from his/her insurance carrier. In this case doctors make sure that they will receive at least the partial payment. Their risk of non-payment is much less and it looks sound and reasonable that they will be prohibited from trying to squeeze out more money from their patients in excess of their deductible / coinsurance amounts. You don’t like what you get – negotiate with the insurance and leave alone your patient.

But these are non-emergency cases. A patient can shop around for doctors, can negotiate the fees, can elect or decline procedures, tests etc. Emergency is quite another matter.

Perhaps you do not remember because there may have been a lot going on...blood, pain, commotion in the ER that particular evening, etc.

That’s the problem, indeed! There are strong moral and ethical issues in it. The patient’s ability to make a decision is significantly impaired by shock and pain. Even worse, if this is a “true emergency” and you were brought to the nearest hospital by an emergency vehicle you have no choice at all.

Imagine for a moment that you got into a car accident and stuck in your car. The police said: “We need to call a special ‘plastic’ technician to get you out. Please, sign up these papers, you will be responsible for a payment. And hurry up – your gasoline is leaking!” Nonsense, right? Looks like extortion. But that’s exactly what is going on in ERs. You got insurance, you have already paid to cover your medical emergency but all in vain! Doctors in hospitals customary use these in-network / out-of-network tricks to get additional money from you. And don’t forget that so-called “steet prices” are much higher than contractual ones (can be 2-4 times more).

That is why I believe that states like New Jersey, New York and California did the right thing to protect their people.

I’d like to reiterate my advice to OP to fight for her rights. She can do it by herself or with a lawyer. Just read this answer below given by an attorney with 15 years of experience to a patient in the similar situation and in the same state (NJ):

[highlight]http://www.justanswer.com/questions/1o1du-experienced-medical-insurance[/highlight]

It’s right to the point.

Scientia potentia est