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Hospital threatening collections

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Hopefully someone here can help but this may get a little long. My son has UPMC for You which is PA Medical assitance. Last summer my wife went to the beach with her parents and our son. On the 2nd day she called me and said he had a high fever and coughing. She wasn't sure what to do as far as where to go. I called the insurance company and asked where we could go out of state. I was informed that the only place you can go is the ER and it would be covered.


I call my wife and tell her that she can go to the ER and it is covered or she could go to a med express type place and it will cost about $100. She ended Up going to the ER and there was no wait and she got seen right away. They did some tests and xrays. He ended up having bronchiolitis. They kept him for half a day and released him.


2 months later we get a bill for $1600. I called the insurance and was told they paid for the service so there should be no bill. I called the hospital and they said they are out of network so we are responsible for the difference between the paid amount and the billed amount. I called the insurance company back and told me that since it is medicaid the hospital has to accept payment in full.


The rep at the insurance company called the hospital to find out why they are not accepting it as payment in full. The rep called me back and said the hospital should be writing it off now. A few months go by and no bill. In Jan we received another bill so I started all the phone calls again. Fast forward to yesterday and I received a bill from the hospital again but this time it says it will be sent to collections if we dont pay.


I don't know all the rules and regs of medicaid but is the insurance rep correct in telling me that I should not be getting billed? If so what should I do to prevent this from going to collections. I was going to send a certified letter threatening action if it goes to collections but I don't want to do that if they actually have the right to send it.

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It looks like a plan for Pennsylvania only. Is your son over 18? Not covered by your insurance under the Affordable Care Act?

He is 4. I understand there are plans specific to areas but my understanding is that ERs must accept Medicaid. Out of state medicaid will pay for services at ERs and hospitals must accept that as full payment. They did receive payment so the issue isn't whether our insurance will pay, it is whether it should be considered full payment.

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Get your EOMB ( explanation of medical benefits) from your insurance.It should show what was billed and what was allowed and what was paid. It might ALSO show what ( if anything) is patient responsibility.


In the meantime follow the guide:( for both you and your wife)


http://www.whychat.5u.com/GUIDEBOOK.html(you do NOT need to delete old addresses)


Once you have the EOMB, send the hospital a REGISTERED letter with a return receipt as follows:


(Your Name)
(City,State, zip)
s.s.# (social security #)
HIPAA Compliance Office
( health care provider creditor)
Dear Sir/Madam;
This letter is in reference to (account #) for services provided to (name of patient) on (date of service).
In regard to the bill on this account in the amount of ($___):
This account is a billing error.
It has been paid,( proof of payment attached) .( attach copy of the EOMB)
It is not a valid bill and is hereby properly disputed, therefore I request complete deletion from all your records.
Please be aware that balance billing on a Medicaid approved bill is a violation of State and Federal statutes.
Please also be advised that under Federal Statutes. the Fair Credit Reporting Act and Consumer Credit Statutes with respect to unsecured PHR identifiable health information of an individual in a personal health record, acquisition of such information without the authorization of the individual. you may be held liable for the actions of
any collection agency's actions. Please note that the these liabilities are under the penalty rules of the Omnibus Final Rule effective 09/23/2013
(a) Duty of furnishers of information to provide accurate information.
(1) Prohibition.
(A) Reporting information with actual knowledge of errors.
Your furnishing of my account information to any collection agency is not in compliance with HIPAA,, and any subsequent reporting of this account on my credit reports to
credit reporting bureaus is a clear violation of Public Law 104-191 ("HIPAA") since there can be no permissible business purpose in divulging protected health information to anyone on an account once there is no longer any payment due.
In addition the new Omnibus Final Rule states:when accounts are paid in full, they can instruct their provider to refrain from sharing information.This letter serves as that instruction.
Please respond, in writing within 10 days that you are processing this request.
I am reserving the right, to take appropriate legal and civil action including reporting to any applicable regulatory authorities any lack of cooperation or compliance with this request.
I hereby waive my rights under HIPAA and any State Privacy Act for the single purpose of your transmission of this request and accompanying documentation in any required report you must make to your E &O insurance carrier.
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