Does the hospitol have a right to do this to us!

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rockyray13

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My husband was having shortness of breath and chest pains on a Friday eve so I took him to the ER. After they ran a bunch of tests on him they decided to admit him so that they could do a stress test on Saturday morning rather than have him wait until Monday. My husbands insurance (for which they had his insurance cards in hand as soon as we arrived at the ER) has a 2000.00 deductable and after that is met they cover 80 percent of the costs and we are responsible for the other 20 percent but this is only if he is actually admitted into the hospital ... As far as ER services go they only will pay 1000.00 towards that with a 250.00 deductable. When the doctor told us that he was going to admit my husband we agreed because we thought the insurance would cover this. Needless to say that about a month later we found out that due to the way the hospital coded his overnight stay by saying he was admitted into the obversation room, instead of actually saying that he was admitted as an inpatient .... his insurance company treated the whole ordeal as ER and wouldn't cover the cost .... They paid of the 12,674.73 bill only 757.68 and a PPO discount of 3,168.65 was also applied leaving us with 8,748.40 out of pocket that they state we are responsible to now pay. The Physician that was taking care of my husband tried to get the hospital to change the coding but they said it was after the fact and nothing could be done. I have tried to get the hospital to lower the cost of this bill since they knew it was a non-covered admittance (they actually wrote that on the forms either friday night or saturday morning) but they tell me that since we provided them with insurance .... they couldn't lower the bill any further .... it was already discounted with the PPO discount. My arguement with them was this ...... "I know that you can't change the codes that you applied after the fact ..... But I also know that it was you neglegence NOT TO TELL US THAT OUR INSURANCE DIDN'T COVER THIS OVERNIGHT STAY. ..... for if you had told us that we could of spoken with the doctor to see if it was an absolute necessity to keep him overnight rather than take him home and bring him back the next morning. I have argued with the hospital until I am blue in the face. My last conversation with them was since you insist upon treating this as an insurance incident then so will I .... I will pay the 2,000.00 deductable that I know we are responsible for and then pay you 20 percent of the remaining 6,748.40 that you say we owe. After that you will get it when I do. I they politely replied that if I don't set up a payment plan with them they will simply turn it over to a collection agency for which I replied back .... Why should I pay for your neglegence ..... It was your responsibility to tell us that our insurance wouldn't cover the way that YOU DECIDED TO CODE MY HUSBAND'S OVERNIGHT STAY IN YOUR HOSPITAL because when we are told that he is being admitted ...... we have no clue as to what you decide to do thereafter unless you tell us.
 
This happens frequently. The hospital had nothing to do with the classification of care- it was the physician who wrote the order to "admit to observation". Observation patients typically receive minimal insurance assistance, but physicians are still free to write orders for costly tests under this status. There are three things you can do at this point. 1. Ask the hospital to remind the medical staff that tests or medications delivered under an observation stay will be billed in full to the patient. 2. Ask the hospital to bill any medication expense to your insurance company directly as though it were an outpatient prescription. They will most likely be hesitant to do this as it involves a significant amount of physician, billing office, and pharmacist time, but it will work. 3. Ask the hospital to set up an extended payment plan.

The hospital was not negligent. If anything, the physician should have realized his limitations when he wrote observation orders. Also- you as the insured should realize that your coverage does not include observation status.
 
Contact the ombudsman for the insurance company. They'll normally work towards a more compromising solution.
 
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