No Pre-Cert now at CA

[Home Brewer 66]

My son was admitted to the Hospital on a Friday night with Monday being a holiday 10 days after birth by his physician. My son was very ill and were pre-occupied with his admittance to the hospital not thinking too much about a Pre-certification. But after we got him settled I attempted to call my insurance company for pre-admittance around 11:30 pm that night. I got a voice recording stating to call back during normal business hours and there was no option to leave a message. I had mentioned this to the attending nurse who said “the doctor who admits him should get your authorization. “ This was a holiday weekend so the next business day was over 3 days away on Tuesday.

 

By Tuesday my son was getting worse and we, as parents, were very distraught and concerned about his survival. As you can imagine calling for pre-certification at the point was the least of our worries and thinking that the doctor would take care of that we never called back.

 

Well our son came out very well and we were home when I got a statement from my insurance company that we were responsible for 2500.00 more that we expected. I called the insurance company to find out why we had that on our summery of benefits and was told because we did not get pre-certification. I tried to explain to that rep how we were admitted, that I did call but could not leave a message, that it was a holiday weekend, and with the gravity of our son’s condition it was very low on our mind to get call back. This was 3 mo after he was released. That rep told me I could appeal which I was going to do. The rep decided to call the billing department at the hospital and then came back on and told me that the hospital said we were responsible for a copayment and some other charges. She then stated that the hospital would waive or write off the 2500.00 charge. I decided that I would not appeal because I did not see the need at the time since I felt I was getting credible information that the charge was being waived.

 

15 months have passed and now I have a bill from the hospital for 2500.00 that they say was reprocessed by by my insurance company. We have paid all our bills from the hospital and have had a zero balance. This $2500 bill came as a surprise when it was previously not showing in our past statements after our conversations with the insurance company or the hospital.

 

We have gotten a varied response from the hospital including that we miss categorized your admittance to it is the Insurance company’s fault. I have called numerous times to both the insurance company and the hospital and even came into their offices with no resolution of this matter. All they want to do is set up a payment method for this bill and see if we qualify for assistance. I do not believe I owe this bill. I have never been bill for something a year latter for charges that never appeared on the original bill. If they made a mistake in there coding or if the person at the hospital never had the authority to say something was written off then they should eat the mistake not try to pawn it off on the customer.

 

Now it has been sent to CA and I have done all the CA stuff to dispute the claim and they have said they verified it.

 

I also have a letter from my sons DR. that states all precertification was done.

 

Any ideas where to go from here?

[breeze]

What kind of hospitalization plan do you have? Do you have a deductible? And then is it 80/20? That's where the insurance pays 80% and you pay 20%.

 

If this truly should have been paid by insurance, you can file a complain against them with your state's insurance department, but it would be good to find out for sure that it was not part of your share of the bill.

[Why Chat]

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You need a written statement from your insurance company stating the information you received verbally that the hospital agreed to waive the $2,500.

 

When you get that you need to send to the hospital, ( not their billing department, but their HIPAA compliance office) the HIPAA letter insert "a" AND "b"

http://whychat.5u.com/hipltr.html

 

Here is the insert edited for your purpose.

This account is in error.

It is a billing error,enclosed please find a statement of explanation of medical benefits from ( name of Insurance Co.) stating that the $2,500 would be waived.

Enclosed please find my remittance of ( pay your deductibles and co-pays)$___) for payment in full of this account.

This payment in full is for services as per the explanation of medical benefits from ( name of insurance Co.)

Please note, my remittance is payable ONLY to (hc provider) and may not be signed over or transferred to any third party collection agency, as this would constitute an additional violation of HIPAA and State Privacy Act rules .

Copies of this correspondence and a copy of the remittance check may be used for any further actions with State or Federal agencies

 

Be sure to follow ALL the instructions and use the WHOLE HIPAA letter. Make sure your payment is by bank money order or bank cashiers check and that the endorsement is printed on the back ( for deposit only (name of hospital).Make a copy of the check/money order front and back as well as any correspondence you may have and a transcript ( a recording would be better) of any further telephone conversations you may have with anyone.

 

You do not need, at this point to dispute the account with the CRA's, nor should you have ANY communication with the reporting CA. As soon as the check/money order is deposited, you can THEN send a dispute to the CRA's. ( the instructions for the dispute and follow up letter to the hospital is posted AFTER all the "inserts" on the HIPAA letter program)

 

I hope that your little boy is completely recovered and I wish you well for your family's future health.

 

If you have any further questions or concerns, please post them in THIS thread, do not start a new post.

[Home Brewer 66]

Thanks for you prompt replies. First our medical plan paid for 100 percent of Hospitalization after a 400.00 co-payment. They other 211.00 was for supplies and pathogy that was only covered at 80%. Those bills were paid before I got the surprise bill of 2500.00 16mo after he was released from the hospital.

 

I did file a complaint with the state insurance commission but unfortunately our company is self insured and the insurance company only acts as an administrator. They suggested I contact the labor department.

 

I have the phone note conversations from the insurance company that states that they called the Hospital and was told the 2500.00 was being waved. I will follow those instructions and see what happens.

 

I also filed a complaint with the BB against the hospital billing. The billing came back that it won’t be reported to the CRA until Dec. I have a month to try to get this resolved.

 

And yes my son is doing well and growing like a weed. He had to have a 100% blood transfusion.

[Why Chat]

Thanks for you prompt replies. First our medical plan paid for 100 percent of Hospitalization after a 400.00 co-payment. They other 211.00 was for supplies and pathogy that was only covered at 80%. Those bills were paid before I got the surprise bill of 2500.00 16mo after he was released from the hospital. Then you do not owe any actual balance, so you can omit the insert "a" payment from your HIPAA letter,

This account is in error.

It is a billing error,enclosed please find a statement of explanation of medical benefits from ( name of Insurance Co.) stating that the $2,500 would be waived.

It is not a valid bill and has been properly disputed, therefore I request complete deletion from all your agent (name of CA)'s records and archives.

 

I did file a complaint with the state insurance commission but unfortunately our company is self insured and the insurance company only acts as an administrator. They suggested I contact the labor department.

 

I have the phone note conversations from the insurance company that states that they called the Hospital and was told the 2500.00 was being waved. I will follow those instructions and see what happens.

 

I also filed a complaint with the BB against the hospital billing. The billing came back that it won’t be reported to the CRA until Dec. I have a month to try to get this resolved.

 

And yes my son is doing well and growing like a weed. He had to have a 100% blood transfusion.

Edited November 20, 2009 by Why Chat