HMO Coverage problem - please, please help

by PATIENT on 2007-01-26 20:02:37

About a month ago I had a heart echo exam in the Outpatient Dept of a local
hospital. I had a referral from my PCP (generic, not for a specific
provider), the hospital accepts my HMO insurance, in fact I had previously
had several other tests done in that hospital with the same insurance and
without any billing problems. They got my insurance info when I was making
the appoinment and once again at the time of the appointment. They sent me
to a room in their Outpatient department where the procedure was peformed.

Today I got a letter from my HMO listing totally unfamiliar provider name
(probably the person who did the test), claiming that he is out-of-network
and that the entire bill is therefore deductible amount - i.e. my
responsibility.

I did everything right, I had insurance, I had a referral, I went to a
hospital that is and has always been in-network, I provided them with my
insurance info twice, yet I am faced with a $400 bill. What do I do?

HMO Coverage problem - please, please help

by MARVIN L. ZINN on 2007-01-28 04:36:35

Patient,

typical problem. Not your fault, but difficult to solve.

I would try:

1. Tell someone in the hospital who sent the bill that it MUST be
sent again to the insurance address and document the fact that it was
paid before and MUST be paid by them again. NO REQUEST, BUT DEMAND!

2. Sent the bill you received directly to the insurance company
with a note, "I'm sorry there was a mistake. Please pay it directly
to the hospital, as you always did in the past and nothing changed.

3. If all else fails, write a message (preferably by a lawyer)
that you REFUSE to pay a bill that the insurance company had total
responsibility to pay, as they did correctly in the past.

No matter what you do, they can cancel your insurance contract.

Insurance companies and pharmaceutical companies and most
hospitals care about profits, not health or customers.

(In my case, a previous injury I had forbids me from having
reasonable insurance, and not one doctor on the list of insurance
companies I am supposed to use will accept me as a patient - because
I am in excellent health after they expected me to die or be
disabled.)

Marvin