WhyChat, Med Experts - Collection after Accord&Satisfact

[flacorps]

Hi folks, I'm looking for a sanity check.

 

Last September, DW ate some bad sushi while she was 6 weeks pregnant. We were not carrying maternity coverage with BC/BS of FL. The hospital used a code that caused them to be declined, but the ER doctor's separate bill was approved, though it was applied to our deductible. The hospital and I both worked BC/BS's appeal process to no avail.

 

Finally in May I paid the hospital the amount BC/BS would have paid them ($500) using "full & final settlement" language on the front of the check. Because BC/BS didn't pay them, they had reversed BC/BS's contractual discount of about $700. I wrote about a month prior to sending the check and told them I didn't agree with that, and they sent back the letter with a handwritten note that the upcharge was proper.

 

Today I get a collection notice for the balance from a local collections firm for the remainder. 30 days and mini-miranda, yada yada.

 

After doing a little research, I found some case law on Page 67 of the attached link, Virginia v. Wills http://www.law.gmu.edu/academics/syllabus/...0/rchapter3.pdf

 

Basically, it says that in order to take advantage of the UCC accord and satisfaction provision that is similar to Florida's, you need a bona-fide dispute and you need to have had good faith in sending the check in settlement. In the particular case, the hosptial had refused $7k a year before the defendant paid, but the defendant sent the $7k accord and satisfaction check a year later anyway. The court found the two prerequisite elements lacking and nailed the defendant (original bill was $17k or something). Looks like courts bend over backwards to give hospitals a break on this sort of thing.

 

Before I saw this case I had planned to handle things differently, but now I think my plan will be to write a letter laying out that we sent the $500 in May because we believed BC/BS should have paid the claim (which we will take up with BC/BS later when all other shoes have dropped), the hospital admitted us with that insurance and never expected more than that until BC/BS denied the claim, and that we paid the money in good faith as an appropriate settlement amount in lieu of conducting a detailed review of the charges to look for the errors that a survey by Equifax says are lurking in 90% of all hospital bills. I believe that will bolster good faith and bona-fide dispute should this ever make court--and may help to convince the CA and/or hospital it shouldn't pursue the claim. I'll also include copies of my prior letters, but not a front and back copy of the check ... I'll just cite date, amount, check number and see if they can find it on their own imaging system (I'll hold the check in reserve).

 

Assuming this is a valid course of action, still up for grabs are:

 

1. Hard or soft tone?

 

2. A C&D element ... just write, don't call?

 

3. A HIPAA element ... and should I write the hospital separately?

 

4. Timing and strategy ... They have about 30 days left on the 90 days the UCC gives for them to send me the $500 back if they want to rescind the "settlement". Should I send the letter quickly and try to appear to be the good guy, secure in the knowledge that hospital bureaucracy couldn't possibly cut such an oddball check in the time remaining (mentioning that if they want to rescind, they can cut us a check for the $500 and then come at us for the $1200), or should I wait until my 30 days with the CA are almost up and not mention the 90 day provision at all, or should I do something in between ... perhaps give them an objectively reasonable two weeks and just a reference to the statute section that I am operating under, leaving them to dope out what they might do, but being able to point to the letter in court as a clear indication that I have not tried to hide the ball.

 

Comments are invited. DW only has one 25 month old paid baddie now--she's near the 700 club. I'd hate for her to acquire a new one, but I don't want to part with $700 I think we needn't pay. I'd hate to acquire a baddie myself, and there is a possibility here. What to do, what to do?

[Why Chat]

Did you file a claim with the sushi restaurant?

 

I have NO idea what will work in this case, however, if the Hospital report states the circumstances of the situation, and hopefully named the restaurant, I would suggest you contact the Hospital and state that they can send the ENTIRE bill to the restaurant.

 

You have, I believe a year to file such a claim, and you should do so, as even IF the restaurant doesn't pay, ( and I would be VERY surprised if they didn't) the fact that you are claiming from another payor will prevent the Hospital from pursuing any claim from you as it would prevent them from getting their full payment.

[flacorps]

Problem is, I have nothing more than the naked assertion that we were there (the restaurant), and there might possibly some notes taken by someone in the ER that might mention the place. Friends picked up the tab (their turn), and they don't keep good credit card records--I already checked with them some time ago to try to pin everything down.

 

Also, DW was newly taking a prenatal vitamin that included a stool softener ... she didn't like it much and quit taking it after this episode (switched to the Sam's club prenatal) ... causation is a bit clouded.

 

Should I obtain the ER nurses' or doctors' notes and look for a reference to that restaurant ... would that be enough to hang my hat on?

[Why Chat]

Send a letter to the restaurant, state the approximate date of your visit. Give them your friend's name and, if he knows, the name of the credit card he used. Explain that you thought your insurance would take care of the situation, and did not want to get the restaurant in trouble,however, you find that your insurance did not cover it,therefore you have instructed the Hospital to bill the restaurant. Tell them you will make no further claim, other than reimbursement of your wife's hospital bill.

 

Send a letter to the Hospital requesting they refund your $500. and bill the restaurant, include a copy of the letter you are sending the restaurant. Request they include any neccessary documentation to the restaurant that may be required for the purpose of proving the treatment for food poisoning from the sushi.

 

All these letters MUST come from your wife, and be signed by her.

[flacorps]

Thanks, I'll incorporate that angle into my plan of attack. Maybe get my $500 back, who knows?

[flacorps]

Wife sent two letters today (drafted by me)

 

The letter to the CA is as follows:

 

First, my address has changed to that listed above. I am in receipt of your notice of <date>. On <date back in may>, the undersigned forwarded to your client a good-faith settlement offer of $500 regarding the disputed balance with respect to this claim, which offer was accepted by the depositing of said check (see attached) under Florida’s version of the UCC. The dispute regarding the balance was that Blue Cross/Blue Shield of Florida had denied the claim (we believed improperly), and your client had subsequently reversed an insurance discount (again, we believed improperly) when both parties clearly believed there was insurance at the time that services were rendered, so your client had not contemplated receiving more than that. Believing the insurance amount to be fair and reasonable, the undersigned paid it in lieu of conducting a detailed review of the billing to look for the errors an Equifax study concluded lurk in 90% of hospital billings.  

 

There being no balance remaining to collect, your client has violated HIPAA by providing information about the undersigned to your firm in an attempt to collect, and your firm will likewise violate HIPAA should it disclose any information to any third party, particularly any credit reporting agency. Additionally, your firm may have liability under the FDCPA and the recent revisions to Chapter 559 Florida Statutes if such disclosure occurs.  

 

Meanwhile, the undersigned has as a courtesy contacted a third party who may have some liability in this matter (see attached). Your firm is instructed to communicate with me only by mail.

 

Please govern yourselves accordingly

 

DW

 

Sushi joint gets this:

 

On or about <date in september>, I dined at your restaurant with my husband <DH> in the company of another couple, <Mr. & Mrs. X>, the latter of whom picked up the check. On the evening of <the next day> I became violently ill with gastroenteritis, until in the early morning hours of the <the day after that> I sought treatment at Hospital X’s Emergency Room.

 

I had not intended to trouble you with any claim for what I suffered, however, due to an ongoing billing dispute I must now cast my net wider than my own insurance carrier, which has denied coverage (I believe improperly) because I was pregnant at the time I was treated. I have attached our bill from <hospital> (showing the full amount of their charges) for your forwarding to your carrier. Please note that our address has changed since that time. My husband has already paid $500 to the hospital out of pocket in an attempt to settle this claim with no success—the hospital took the money and continued to bill on the balance, which we do not want to pay. We have ordered the ER records from the hospital, but have not received them yet.

 

If your insurance carrier has any questions or concerns, they may of course contact us.

 

Sincerely,  

 

DW

 

As Andy Devine (as well as most other children's TV personalities) was supposed to have said in the urban legend "That ought to hold the little bastards."

 

The fun begins.

[flacorps]

No further shoes have dropped. I'm waiting with bated breath. If CA has a canned response for this sort of thing, they haven't used it yet.

[flacorps]

OK, a couple more letters went back and forth, and the CA just folded its tents and said it sent the matter back to the hospital.

 

CA's closing letter was mailed the same day I DV'd them and cross copied them and the hospital on a letter I sent the hospital specifically declining to have any of the DV information released to the CA and advising that from our viewpoint the matter was PIF, and the hospital had better have its ducks in a row if it believed otherwise and wanted to furnish validation information to the CA.

 

No telling whether the hospital will look for another CA, but they've slowed down greatly in the pace of their lawsuits, and I know as a lawyer that if they came to me with the case they have against this particular patient, I'd tell them there's lots of other cases to work on where they actually have a decent chance of winning.

 

This appears to be a technique Floridians can use to deal with the outrageous jacking of charges that hospitals do when insurance is either nonexistent or denies the claim.

 

A better technique would be to vote "yes" on the amendment to the state constitution this fall that requires hospitals to bill you the same amount they would bill the insurer/agency with whom they have the lowest-priced deal for the same services. Ignore the predictable screaming from the health care sector's shills.

[foshizzle]

FABULOUS thread!

 

In our negative experiences with insurance companies, we've found that the best method to achieve expiditious conflict resolution is just to report the bastards to the Insurance Commissioner.

 

You'd be amazed to watch the dance they do for the Dpt of Insurance.

 

But then, in NC, the #1 job of the DOI is to deal with complaints.

[screwedbysears]

If I could chime my insurance is jacking me around we have a $1500 out of pocket limit per person that was done on my wifes first operation in 2003 then she had another one in 2003 and all of sudden we have'nt meet our out of pocket. even though here first bill was over $20,000 They just don't want to pay.

[Why Chat]

If I could chime my insurance is jacking me around we have a $1500 out of pocket limit per person that was done on my wifes first operation in 2003 then she had another one in 2003 and all of sudden we have'nt meet our out of pocket. even though here first bill was over $20,000 They just don't want to pay.

 

Read your policy CAREFULLY, there are TWO types of "maximum" out of pocket limits, one is PER YEAR, the other, (as is likely in your case) is similar to standard policies and is on a per confinement or per surgery basis, unless the confinements or surgeries are within a certain time limit, usually 90 days.

[screwedbysears]

Its per year we have really good insurance its just that United health care screwes it up. they didn't cover $900 bucks for one pre op procedure because they said it was preventive Yea right hospital said they coded it pre op UHC said the coded preventive.

Still fighting that battle.

migth have to change name to screwedbyUHC

[Why Chat]

Its per year we have really good insurance its just that United health care screwes it up. they didn't cover $900 bucks for one pre op procedure because they said it was preventive Yea right hospital said they coded it pre op UHC said the coded preventive.

Still fighting that battle.

migth have to change name to screwedbyUHC

File a complaint with your State Insurance Commission.

[screwedbysears]

When I get the review I will have to see what they say. I will be getting a paper trail ready.Its funny on their website where it shows all the claims paid it shows right up to the 1500 then they pay the rest. Then in oct when she had her other operation it starts showing where we have out of pocket expenses again when I pointed it out to them they said we don't know why. But according to them I never meet our $1500 out of pocket.

[flacorps]

Update:

 

Hospital sent closing letter saying the account is paid in full (they've decided they're not getting the money and they're going to live with it and they've found an accounting entry for the charges they're having to eat) ... the $700 they're not getting is now termed a "courtesy discount" ... some courtesy.

[flacorps]

Just adding to this thread, I had another provider for DW who

balance-billed on something BCBS took a l-o-o-n-g time paying, and

back in May I had paid that provider the full amount of their bill at that time with another "full and final settlement, account XXXX all charges through April 30, 2004" notated check.

 

So when I got balance billed, I pointed out that #1 I was being balance billed, and #2 the payment that I provided back in May was under a restrictive endorsement (included copy of check and copy of Florida Statutes pertaining to same), and the provider/billing agency quickly folded.