CA Sent a Copy of the Bill. How Should I Respond

Tomm19325 · May 24, 2013

Hello,

I wanted to get some advice from you folks once again. Last time I posted here, I received highly valuable advice from WhyChat and Clyde's Mom.

I owe over $5,000 to a hospital mainly for two visits to the Emergency room.

At the time, I did have health insurance.

But since I never previously had health insurance \, I wasn’t familiar with how the rules actually work – deductibles, out of pocket expenses, etc. So I mistakenly thought most of the bill would be covered by insurance.

I’ve requested and received Explanation of Benefits letters from the insurance company.

However, I don’t really understand the letters.

I’ve called and talked to the insurance company several times on the phone and they’ve briefly explained the letters. But I honestly still don’t understand how they’ve calculated what they paid, and how much I’m responsible for.

In any case, the hospital sent the bills to a Collection Agency (CA).

I received highly valuable advice from this website that was really helpful.

Based on the advice I received here, I sent out debt validation letters for the bills.

The CA has written back and attached a copy of the bills and all the charges.

I’m struggling financially so I haven’t been able to pay the premium anymore and I’ve had to cancel the insurance.

And I can’t really pay the over $5,000 I’ve been charged.

Although I don’t understand medical terminology, in examining the bills the CA recently sent me, I was able to find two services for which the hospital charged me that they never provided.

I also believe some of the charges are simply outrageous.

I want to dispute the two inaccurate charges and the outrageous amounts.

And I also want to work out some sort of payment plan for the balance since there is no way I can pay over $5,000.

I’ve contacted the hospital several times, but they are not interested at all in dealing with me and they’ve told me to deal directly with the CA.

Given the dire circumstances, how should I try to resolve this matter?

It appears I don’t have any good options, but is there a strategy that might produce something less negative than the others?

I would greatly appreciate your thoughts, ideas and advice. Thank you very much for your kind attention and help!!!

Thank you!!!

Tom

Clydesmom · May 24, 2013

Many patients feel that what the hospital charges is outrageous but the contracted fee with your insurer is what it is and they cannot discount it. They are contractually obligated to bill you the amount they agreed to with BC/BS. No provider will discount it as it is illegal rebating and can get them sued by the insurer.

If they are charging for a procedure you did not have you can and should dispute that. Beyond that, if you don't make arrangements to pay you could find yourself being sued.

Why Chat · May 24, 2013

Did you follow any of the advice??

http://www.whychat.5u.com/GUIDEBOOK.html

http://www.whychat.5u.com/GUIDE%20HIPAA%20PROGRAM.html

Your EOMBs should show "patient responsibility" that is the NET amount that YOU are actually obligated to pay.

SouthernTreat · May 26, 2013

I am working through a similar situation. The CA has verified with the CRA and has responded to my DV. Is this what I should send to the CA next?

http://whychat.5u.com/ltrcavalhipaa.html#DISPUTE

Edited May 26, 2013 by SouthernTreat

Why Chat · May 26, 2013

I am working through a similar situation. The CA has verified with the CRA and has responded to my DV. Is this what I should send to the CA next?

http://whychat.5u.com/ltrcavalhipaa.html#DISPUTE

Please start your own thread.

It is impossible to give accurate advice as everyone's situation is different.

In general-- if you are following the HIPAA letter program AFTER opting out and deleting old addresses, and have sent the initial dispute to the CRAs and had "verification" and sent the medical DV to the CA and had a response that documents a current relationship with the OC and matches your records ( EOMBs) and the date of service is recent, then the next step would be to pay the OC with the HIPAA letter insert "a". Otherwise, please post YOUR data in your own thread.( the link you posted http://whychat.5u.com/ltrcavalhipaa.html#DISPUTE) would be appropriate IF the account is older than 2 years and/or if the response from the CA did not match your records OR did not demonstrate a CURRENT business relationship with the OC)

Tomm19325 · May 28, 2013

Thanks very much, Clydesmom, for your time and kind help.

I will try my best to dispute the bill based on the inaccurate charges.

But I think you are right.

I will eventually need to make arrangements to pay, otherwise, as you say, I will get sued.

Thank you once again for your kind help.

Tom

Tomm19325 · May 28, 2013

Thank you once again for your kind attention and time, WhyChat.

I tried my best to follow your advice.

So I used your letter to the collection agency as my template and sent it to the CA.

The CA responded and sent two bills that amount to over $5,000.

In reviewing the bills, I noticed several issues.

1. The hospital did an ultrasound for which they’ve charged $1,192.

I had the same ultrasound of the same area of my body done about a year earlier.

Since I didn’t have insurance at that time – and no longer have insurance now – I had to pay cash for the service.

The medical clinic charged me under $200 (around $180 or so) for the ultrasound.

The same ultrasound of the same area of the body was done by the hospital, and on the bill it shows that the hospital charged $1,192 for this service.

2. In addition to this ultrasound, the bill shows that the hospital charged me for a second ultrasound that they allege they performed on my abdomen on the same day.

They’ve charged $930 for this service.

However, the hospital never did an ultrasound on my abdomen. They only performed one ultrasound on another area of my body for which they have charged $1,192.

3. Unfortunately, I don’t know anything about medicine, and I don’t understand medical terminology.

It appears to me that there are many services that the hospital charged me for which I really don’t understand.

4. Another thing that makes me suspicious is the fact that on another visit to this hospital/clinic, they gave me a holter monitor to wear for 24 hours to monitor my heart activity.

Since I never had health insurance in my life before – except the 2 years I recently had it with this insurance company – I wasn’t aware of how the system works (deductibles, out of pocket expenses, etc.).

I assumed that most of the cost of the holter monitor service cost would be paid by the insurance company.

The CA’s bill shows that the hospital/medical clinic has billed me for two items related to this service:

a. “Holter Record/Hkup/Disc A” $697

b. “Holter 48 hour Scan Analysis” $832

I have two problems with this bill.

a. I wore the holter monitor for only 24 hours. So why does the bill show “Holter 48 hour scan?

I have a feeling that, once again, they are trying to pad the bill.

b. I remember I paid the hospital/medical clinic around $350 related to this service.

But I don’t see any adjustment on the bill for the amount I paid.

In fact, on the bill the CA sent me, it only lists (a) the amounts charged by the hospital/clinic, ( the amounts paid by the insurance company, © the principal balance remaining, (d) accumulated interest to date, and (e) total currently due.

The bill doesn’t show the amounts I paid.

To be honest, I paid under $1,000 during that year but still, I would think that the bill should also list and factor in these payments.

In any event, there is no way I can pay the $5,000 the CA says I owe so I want to work out some sort of payment plan.

But I also want to see if I could get some adjustments for the incorrect charges.

I’ve contacted the hospital several times, but they are not interested at all in dealing with me and they’ve told me to deal directly with the CA.

It appears I don’t have any good options, but is there a strategy that might produce something less negative than the others?

Also, how much time do I have to respond to the CA’s bill/debt verification letter?

I would deeply appreciate if you could kindly provide me with any advice or guidance.

Thank you very much for your kind assistance. I really appreciate your thoughts and help!

Tom

Why Chat · May 28, 2013

I don't understand your last post.

You said you followed my instructions??

You opted out??

You deleted old addresses?

You sent the initial dispute letter to the CRAs??

Do you have your EOMBs??

WHY are you sending letters to the reporting CA instead of sending the inititial dispute letters to the CRAs??

Tomm19325 · May 29, 2013

Hi WhyChat,

Thank you very much you for your kind attention and time.

Sorry about my confusing post.

I tried my best to follow your instructions, but it seems I probably have misunderstood what you have mentioned on the website.

I didn’t opt out because the CA already has all my information.

However, in retrospect, I think I should opt out in order to avoid future problems. I will make sure to do that.

I haven’t deleted my old address because the CA already has my current address.

I didn’t send the initial dispute letter to the CRA, because the letter was sent to me by the CA.

At this point, I don’t think that the CRA is aware of what’s going on since I don’t believe the CA has reported the bill to the CRA yet.

These bills are from November 2012 to January 2013. So they are fairly recent bills.

The CA initially sent me a letter stating that I owed over $5,000 in medical bills.

I thought that if I didn’t respond to the CA’s letter within 30 days, they could report the bill to the CRA.

So I sent a debt validation letter to the CA using your letter as a sample.

The CA sent copies of the bills.

As I mentioned in the above post, I noticed several inaccuracies on the bills.

I was thinking of challenging the bill based on the inaccuracies.

I do have copies of the insurance company’s Explanation of Benefits, but I really can’t understand the material.

I’ve contacted the hospital several times, but they are not interested at all in dealing with me and they’ve told me to deal directly with the CA.

It appears I don’t have any good options, but is there a strategy that might produce something less negative than the others?

How much time do I have to respond to the CA?

I would deeply appreciate if you could kindly provide me with any advice or guidance.

Thank you very much for your kind assistance. I really appreciate your thoughts and kind help!

Tom

Why Chat · May 29, 2013

Hi WhyChat,

Thank you very much you for your kind attention and time.

Sorry about my confusing post.

I tried my best to follow your instructions, but it seems I probably have misunderstood what you have mentioned on the website.

I didn’t opt out because the CA already has all my information. The purpose of the opt out is to prevent the CRAs from SELLING your updated data to data miners

However, in retrospect, I think I should opt out in order to avoid future problems. I will make sure to do that.

I haven’t deleted my old address because the CA already has my current address. The fact that THIS CA has your current address is not the issue, you do not know what address is in their automated (e-oscar) response system used to verify disputes

I didn’t send the initial dispute letter to the CRA, because the letter was sent to me by the CA. If you do not wish to follow the HIPAA letter program, that is your privilege, however the initial dispute letter to the CRAs is an essential part of the program

At this point, I don’t think that the CRA is aware of what’s going on since I don’t believe the CA has reported the bill to the CRA yet. ??? You don't BELIEVE?? are you saying you haven't even bothered to get your credit reports??

These bills are from November 2012 to January 2013. So they are fairly recent bills.

The CA initially sent me a letter stating that I owed over $5,000 in medical bills.

I thought that if I didn’t respond to the CA’s letter within 30 days, they could report the bill to the CRA.

So I sent a debt validation letter to the CA using your letter as a sample.

The CA sent copies of the bills.

As I mentioned in the above post, I noticed several inaccuracies on the bills.

I was thinking of challenging the bill based on the inaccuracies.

I do have copies of the insurance company’s Explanation of Benefits, but I really can’t understand the material.

I’ve contacted the hospital several times, but they are not interested at all in dealing with me and they’ve told me to deal directly with the CA.

It appears I don’t have any good options, but is there a strategy that might produce something less negative than the others?

How much time do I have to respond to the CA?

I would deeply appreciate if you could kindly provide me with any advice or guidance.

Thank you very much for your kind assistance. I really appreciate your thoughts and kind help!

Tom

Do you have the original bills from the OC??

Do you have your EOMBs ??

Do you know how to read the EOMBs and find the NET amount that is PATIENT RESPONSIBILITY??

Tomm19325 · May 30, 2013

Hello WhyChat,

I greatly appreciate your taking the time to read my post and to provide me with valuable advice.

I’m not knowledgeable about credit issues and how to deal with CAs. So it’s not surprising that I failed to understand your HIPAA letter program.

Based on your response, it’s evident that I’ve really screwed up.

I’m going to opt out right away.

If I’ve understood what you mentioned, then I believe I don’t need to delete my address given that I haven’t moved since the date of the medical services.

Since the CA contacted me very recently (in April 2013), I didn’t think that they would report the matter to the CRAs yet.

I guess I was wrong about that so I will ask the CRAs for my credit report.

I also thought that if I didn’t respond to the CA within 30 days and ask for validation of the debt, they could report the debt to the CRAs. That’s why I wrote to the CA and asked for copies of the bills.

However, I probably am wrong about that too. The CA may have already reported this issue to the CRA and listed it on my credit report.

I do have the original bills from the hospital/medical clinic.

The bills relate to services provided in October 2012, December 2012, and January 2013.

Several items listed on the bills are inaccurate. So I think I will write to the hospital/medical clinic to get the bill revised and corrected. Is that okay?

I also have the EOMBs.

However, I’ve been having problems understanding the EOMBs since I’ve never had insurance before, and I’m not familiar with how the billing works (deductibles, out of pocket expenses, etc.)

I’ve also gone to so many doctors, emergency rooms (twice), and had so many tests done due to my poor health that the bills get rather complicated.

In my opinion, several amounts listed on the bills as “patient responsibility” are wrong.

Each time I’ve called the insurance company over the phone for an explanation of the things I don’t understand, each insurance representative has given me a different answer.

But I am beginning to develop some understanding of the EOMBs and what I believe are the correct calculations and the amounts I am responsible for and what amounts the insurance company should be responsible for.

I was thinking of writing to the insurance company, attaching my calculations, and letting them know that, by my calculations, there are a few items on the bills that they are responsible for. Would that be okay?

I guess I made a big mistake in responding to the CA and asking for debt validation and copies of the bills.

However, since I’ve already corresponded with the CA and they've sent me copies of the bills, I was thinking of writing to the CA and pointing out that:

(a) The hospital/medical clinic has listed several inaccurate charges on the bills so I’m contacting the hospital/medical clinic directly to clarify these charges;

( The insurance company should have paid for several items that are listed on the bills and I am writing to the insurance company requesting that they pay for these items; and

Given the way I’ve messed up, would it be okay to write to the CA and inform them of the above issues?

Or is it best to ignore the CA and deal directly with the CRA?

Unfortunately, I didn’t handle this issue properly from the beginning so I’ve made things a lot more complicated and difficult than they needed to be.

Once again, I would deeply appreciate any advice and guidance you could provide.

Thank you very much for your kind attention, time and assistance!

Tom

Why Chat · May 30, 2013

Hello WhyChat,

I greatly appreciate your taking the time to read my post and to provide me with valuable advice.

I’m not knowledgeable about credit issues and how to deal with CAs. So it’s not surprising that I failed to understand your HIPAA letter program.

Based on your response, it’s evident that I’ve really screwed up.

I’m going to opt out right away.

If I’ve understood what you mentioned, then I believe I don’t need to delete my address given that I haven’t moved since the date of the medical services. CORRECT

Since the CA contacted me very recently (in April 2013), I didn’t think that they would report the matter to the CRAs yet.

I guess I was wrong about that so I will ask the CRAs for my credit report.

I also thought that if I didn’t respond to the CA within 30 days and ask for validation of the debt, they could report the debt to the CRAs. That’s why I wrote to the CA and asked for copies of the bills.

However, I probably am wrong about that too. The CA may have already reported this issue to the CRA and listed it on my credit report.

I do have the original bills from the hospital/medical clinic.

The bills relate to services provided in October 2012, December 2012, and January 2013.

Several items listed on the bills are inaccurate. So I think I will write to the hospital/medical clinic to get the bill revised and corrected. Is that okay? NO!! do NOT use the "bills" as a reference point. Use ONLY the EOMBs. You need to understand that the "bills" from the OC are NOT the "real" bills, they are the "retail" charges BEFORE applying the mandatory discounts from your insurance. They are ONLY allowed to charge you what the insurance ALLOWS they are NOT allowed to "balance bill" Your EOMBs should show the ALLOWED amount, what the insurance paid and what YOUR obligation was, which should ONLY be your co-pay and deductibles

I also have the EOMBs.

However, I’ve been having problems understanding the EOMBs since I’ve never had insurance before, and I’m not familiar with how the billing works (deductibles, out of pocket expenses, etc.)

I’ve also gone to so many doctors, emergency rooms (twice), and had so many tests done due to my poor health that the bills get rather complicated.

In my opinion, several amounts listed on the bills as “patient responsibility” are wrong. ONLY LOOK AT THE EOMBs

Each time I’ve called the insurance company over the phone for an explanation of the things I don’t understand, each insurance representative has given me a different answer.

But I am beginning to develop some understanding of the EOMBs and what I believe are the correct calculations and the amounts I am responsible for and what amounts the insurance company should be responsible for.

I was thinking of writing to the insurance company, attaching my calculations, and letting them know that, by my calculations, there are a few items on the bills that they are responsible for. Would that be okay? NO, do not make things even more complicated than they are. If your insurance Co refused to pay for something because it was not "coded" properly or not covered because of some other reason, that is NOT an issue for you now. If a health care provider accepts insurance, they MUST accept the discounted amounts allowed and they MUST write off the rest

I guess I made a big mistake in responding to the CA and asking for debt validation and copies of the bills.

However, since I’ve already corresponded with the CA and they've sent me copies of the bills, I was thinking of writing to the CA and pointing out that:

(a) The hospital/medical clinic has listed several inaccurate charges on the bills so I’m contacting the hospital/medical clinic directly to clarify these charges;

( The insurance company should have paid for several items that are listed on the bills and I am writing to the insurance company requesting that they pay for these items; and NO NO NO

© Once these issues are resolved, I will pay the correct balance to the hospital/medical clinic.

Given the way I’ve messed up, would it be okay to write to the CA and inform them of the above issues? NO NO NO

Or is it best to ignore the CA and deal directly with the CRA?

Unfortunately, I didn’t handle this issue properly from the beginning so I’ve made things a lot more complicated and difficult than they needed to be.

Once again, I would deeply appreciate any advice and guidance you could provide.

Thank you very much for your kind attention, time and assistance!

Tom

Tomm19325 · June 6, 2013

Thanks so much, WhyChat.

I will make sure to follow your valuable advice.

I deeply appreciate your attention, time and patience!

Thank you!

Tom

juswannaBfree2 · June 6, 2013

Maybe I can help you to understand the way insurance works a little bit here.

While it is true for providers (hospitals, doctors, etc.) who are IN-NETWORK with your insurance company are not allowed to "balance-bill" you for the amounts over their contracted "allowed amounts" with your insurance company, that does not hold true for OUT-OF-NETWORK providers (so you may want to find out if that particular hospital is in or out of network with your insurance company. You should be able to tell by your EOB, or a "provider search" on the website of your insurance company. If you do a provider search on the website of the insurance company, and the hospital comes up, that usually means they are in network). I am assuming that is pretty much across the board for most insurance companies, if not all of them, as far as out of network providers not having to follow the contract (since that is the whole point of in and out of network benefits anyway).

For out of network benefits, the patient may be responsible for the amount over the allowed amount; but with that being said, if the provider is out of network, there is no "contract" they will be breaking if they come to an agreement with you about discounting the services, they can charge what they want. With this last point, you stated how you were charged a significantly less amount during a previous visit than what was being charged now; so they could follow that same discount now, if they wanted, for that same service. The providers can write-off the entire amount if they wanted to, it is ultimately up to them when they are out of network. Also, if you have financial hardships, most hospitals have an "assistance" program for people who meet certain requirements (such as income, etc.), you may want to check into seeing if that is a possibility with the hospital you went to (sometimes there is a deadline on that, so I would hurry and find out). Just because the hospital "accepted" your insurance, does NOT mean they have to follow the insurance companies guidelines if they are not in network.

As far as the deductible, coinsurance, and out of pocket go, with most policies, you must meet the deductible before the insurance will start paying for their portion of the coverage. Once that coverage starts, the percentage you owe will go toward your out of pocket on the policy; and unless your policy states otherwise, once that deductible and out of pocket has been met in full, your insurance will then cover at 100% of the allowed amounts (if the provider is out of network, then the patient may still be responsible for the amount over those allowed amounts) for the remaining of your calendar or contract year.

I will give you an example, and hope this helps you understand a little bit better (I know insurance can be confusing). Say, for emergency room services for an in network hospital, benefits are: you have a $600 calendar year deductible, coverage at 80/20 (insurance pays 80%, you pay the remaining 20%), and a $1200 calendar year out of pocket; you must first meet that $600 deductible in full before the insurance will start paying their 80%. So with an example of $5000 billed to the insurance (this is assuming that you have not met any of your deductible or out of pocket accumulations), the first $600 of that will be directly out of your pocket, then the remaining amount will be paid by the insurance at 80% of the allowed contracted amount, up until the $1200 out of pocket has been met. I will try to post a rough calculation for you:

$5000 is the total the provider billed to your insurance company, & your insurance company has accepted this amount per the contract.

-$600 which would be your deductible. (So this is now met in full and you no longer have to worry about the deductible for the year.)

--------

$4400 the amount remaining after you have paid your deductible.

x .80 the 80% the insurance company pays.

--------

$3520 the actual amount the insurance paid of the $4400 remaining amount.

Then you would take:

$4400 the amount remaining after you have paid your deductible.

-$3520 which is the payment from the insurance company.

---------

$880 the amount remaining that is "patient responsibility", which is the remaining 20%.

So you would owe the $600 deductible and the 20% coinsurance of $880, which brings you to a total of $1480.

Now, there are different variables with your out of pocket dependent upon if the insurance company applies what you pay toward your deductible, to your out of pocket. Not all policies do. If your deductible is not applied to your out of pocket, then you would owe the total $1480; but you would also deduct the $880 from your $1200 out of pocket, leaving your remaining out of pocket expense at $320 (so if you had any additional services with other in network providers in the future, during the same calendar or contract year, you would only have to pay $320 for benefits that fall the same as the emergency room visit benefits were, the insurance would then pick up 100% of the allowed amount of your remaining services for the rest of the calendar or contract year {if you have any services that fall subject to a copay, such as an office visit, THAT (the copay) may still apply; also dependent on whether or not your insurance applies your copays to your out of pocket expense}).

If your policy DOES apply your deductible to your out of pocket, then you would only pay $1200 of that $1480, and the insurance would pick up the rest at 100% of the allowed amount; so they would pick up the remaining $280.

What your out of pocket expense is, is just that, the total expenses you will pay out of your pocket for the calendar year. Copays and deductibles do not always apply to that amount, so if they do not, then the 20% you are paying out of pocket from your coinsurance would be all that would go toward the "out of pocket expense"; you would still be responsible for copays, and of course the deductible.

I am assuming by your post, that you do have a deductible, coinsurance, and out of pocket that is applying to these benefits, which is why I went with this scenario.

I hope that all made sense. It is really late, and I am really tired, lol. I will try to find a moment to pull this up again tomorrow (it has been a while since I have been on here) to see if you have any questions, or if I need to edit anything. I could continue to explain how insurance works, and its different variables, but I do not want to confuse you. I really hope this helped!

Tomm19325 · June 11, 2013

_{Thank you very, very much JuswannaBfree2 for your time and assistance!}

_{I really needed to learn how insurance works and I’m deeply grateful to you for giving me a good education.}

_{Since I have MAJOR learning difficulties, ADD and related problems, it was hard for me to understand what you mentioned.}

_{I therefore had to read and reread what you wrote several times and make notes.}

_{I’m sure the example you gave was very clear. It just takes ME a long, long time to understand ANY issue. Most people understand insurance matters fairly well, but for me it’s like nuclear physics.}

_{After reading your post several times and making notes, I was finally able to understand the example you gave.}

_{I think I can now make the calculations for my case.}

_{Thank you once again for your time and help. I greatly appreciate it!}

_Tom

anonyman · June 11, 2013

Tomm,

I skimmed over your post.

I would stick to following Why Chat's program.

You won't have to put much mind to it, just follow the program and it should get those off of your report.

If you drift in different directions, you wont get far.

Plus if you've paid even a single penny to the collection agency, you won't be able to benefit from the program and it could stay on your report for 7 years.

Tomm19325 · June 18, 2013

Thanks Anonyman.

I will definitely follow WhyChat's program.

Thank you for your kind advice. I greatly appreciate it.

Tom

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CA Sent a Copy of the Bill. How Should I Respond

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