Here is some follow-up from my daughter’s broken arm billing thread from earlier today. By way of background, my 13 year old daughter fell and injured her wrist when she was snowboarding in February. We were on vacation in Tahoe, about 180 miles away. My wife took her to the “Emergency” clinic at the base of the mountain where she was seen and evaluated. She was x-ray’d and diagnosed with a buckle fracture of the left radius. She was given a temporary splint and told to see her doctor when we got home on Monday. The whole visit took about 2 hours. Much of that time was spent getting a prior authorization from our insurance company. We paid the $20 copay required for this kind of visit (Urgent Care).
We did eventually go to the UCSF orthopedics clinic where she was seen and treated again (and again x-ray’d). This time, she was fit with a custom splint and this took about 2 hours.
Yesterday, I got a bill for $448.66 which was for the balance of what was not paid by my insurance company. Even after 26 years in medicine and even growing up with a father who is a doctor, I did not understand that there is no deductible for my HMO insurance plan for emergency or urgent care. My obligation was and is to pay the $20 copay.
So to learn more, this morning at 9:25, I called my insurance provider. I had a pleasant conversation with the representative and explained that I had gotten a bill from the provider. I said I wanted to call to understand what my obligation was. He said that I was obligated to pay the $20 copay and that was it. He said, “it is odd that they are balance billing you”.
He advised me to call them and gave me a number to provide to them for them to call the insurance company with questions about billing. That call took 9 minutes.
Next, I called the 800 number on the bill. It seemed to be a big billing company. I waited on hold for 10 minutes while listening to muzak. I eventually spoke with the agent and explained the issues again. He said that the insurance company had not paid the full amount and he explained to me that since this was out of network, there was no contracted rate.
He said that there had been an appeal sent to my insurance company on May 10 and that it had not yet been paid so he explained that I am obligated to pay the balance.
I said, that sounds like “balance-billing” and I understand that to be illegal in California. He said that was not true and invited me to write an appeal letter.
He said that I should call back my insurance company to understand why they did not pay the full amount. I responded that I had been spending a lot of time on hold and on various calls. He apologized and said Mondays were busy. He suggested that I try to set up a 3-way call between them and the insurance company.
I asked him if he thought the bill was coded correctly and he said he was not a coder. I asked who coded the visit, whether it was the doctor’s office or them. He said they coded it.
Next, I called my insurance company back. As an aside, they were extremely nice. She went through the notes and the bills and said, “they are balance billing you”. I said, that was my thought too. She said she would be willing to call them on my behalf. I told her that the billing agent had suggested we do a 3-way call. She agreed and asked for the number.
She conferenced me in and after we introduced each other, the insurance company rep told the billing agent (someone new) the story and explained that they paid this as a part of a multi-plan contract and the balance of $438.66 was not allowable per that contract.
The billing agent asked if the insurance company had submitted the explanation of benefits (EOB) when they made their payment of $1125.34. She said they had not. The billing agent asked if they could please send over the EOB. The billing agent asked what the status of the May 10 appeal was. The insurance rep said she did not know. The billing agent said she would re-submit the bill.
The insurance agent then asked what they could do so that her member (me) was not sent to collections. The billing agent said they would put a 35-day hold on the bill and said for me to call back when I get the next bill. And then again, she asked to please send the EOB.
We hung up with the billing agent and the insurance rep asked me to stay on the line. When we were back alone, she said, “they cannot balance bill you”. I said I agreed. She told me to please keep them updated. I promised I would.
Overall, this took just under an hour. At the end of the day, it is not resolved. There is a dispute between the billing company and the insurance company over this bill but the person left responsible is me. I am an experienced physician and even I did not understand any of this. I was not aware of multi-plan contracts or that they existed. I just feel like I am stuck in the middle of a dispute between two parties, but that somehow I am the one with the most to lose. I can only imagine how a lay-person might feel and fully expect that most people end up just paying this bill. The cynic in me wonders whether there might be an effort to bill like this expecting that most people will just pay it. It is astonishing really.