California Health Insurance

[wysiwyg]

Jurisdiction

California

I went to a urgent care in March of 2014 approved by Cigna PPO plan I had, due to chest pains I was experiencing for over a weeks time. When I went in to be examined, they found that I had irregular heart rhythm, so they said they needed to transport me to the hospital for further testing that they weren't able to do at the Urgent Care. The Urgent Care said that they needed to take me in a ambulance. I remembering asking them if this was covered by my insurance, because I would drive myself if not. They said yes, and they also told me I couldn't drive myself. So after all was said and done, I got the bill from the ambulance service stating that my insurance was not paying the bill for the ambulance. I called Cigna and asked why they weren't paying the ambulance, when in my Explanation of Benefits stated that I was covered, they proceeded to tell me that it was coded wrong from the ambulance company and I needed to call the ambulance company to change the code and then file a appeal with Cigna. I did as they instructed me, and spoke to them after 30 days and they told me it would be paid. I called the ambulance company to let them know that Cigna would be paying the fee's for the ambulance. I never received another bill stating that I still owed or I didn't receive an EOB from Cigna, letting me know what I would be responsible for. As of January 2016, I was in the process of refinancing my house and when they pulled my credit report there was a collection from a collection company representing the ambulance company in the amount of 5762.00, when originally it was 3292.12. I've called the insurance company several times, over a months time, when I finally spoke with someone that told me that they would pay a part of it, around $200.00, but they weren't going to pay the full amount due to the Urgent Care used an Out Of Network ambulance and since this happened in 2014 and my insurance was with a prior company that I worked with, the funds were no longer available to pay the claim. I told them, how was I suppose to know what ambulance company the Urgent Care was using and why didn't they ever send me anything stating what I would be responsible for. The lady I was dealing with at that time, asked me to resend all my appeal papers (which I did) and I asked her to send me proof of the EOB they supposedly sent me, which she still hasn't sent. My question is, the incident happened in San Diego County and now I'm living in the San Luis Obispo County, if I choose to take this to Small Claims, will I have to file small claims in San Diego County or can I file in the county I live in now?

 

[ElleMD]

What exactly would you be suing them for? and who do you think you can sue?

 

[wysiwyg]

What exactly would you be suing them for? and who do you think you can sue?

Thanks for responding, I think I would be suing because when I went through the appeal process through Cigna, because it was originally coded wrong from the ambulance, they told me that I passed the appeal and they were going to pay the bill, but I never received an EOB stating that it was paid. Then when I got my credit report there was a collection from the ambulance company. When I called Cigna, they said they would only paid 224.00 of the 5700.00, due to the Urgent Care that they sent me to used an Out of Network ambulance service, which I don't think I'm responsible for making sure they used an In Network ambulance. As a patient, was I suppose to tell them to make sure that they use the correct ambulance service? The long and short of it....is I did what they asked me from the beginning to file an appeal about the wrong coding and now they are telling me that they are not going to pay for a totally different reason such as they used an Out of Network Ambulance, which they never sent me anything stating that they were not going to pay. The interesting part is, I received a recent EOB stating that they would pay $224.00, so I think they messed up, because if that's all they were going to pay on a bill that happened over a year ago, then why wasn't it paid back then. I also asked them to send me an EOB from the time of the service stating that was the amount they were going to pay and the woman I spoke to said she couldn't find it. I hope this makes sense?

 

[ElleMD]

Whether you have any recourse lies in your actual contract with the insurance company. Typically you are responsible for any medical charges, insurance just off sets that cost based on what the contact/plan agreement states it will cover. Often there is a carve out for out of network in emergencies, but you will have to check your policy. In any case responsibility for paying any bills still falls to you. I have a hard time believing you were never once contacted and received nothing in the mail about the bill. When it comes to getting paid, medical providers are relentless and only send to collections as a last resort. Collections costs the provider money.

 

[wysiwyg]

Whether you have any recourse lies in your actual contract with the insurance company. Typically you are responsible for any medical charges, insurance just off sets that cost based on what the contact/plan agreement states it will cover. Often there is a carve out for out of network in emergencies, but you will have to check your policy. In any case responsibility for paying any bills still falls to you. I have a hard time believing you were never once contacted and received nothing in the mail about the bill. When it comes to getting paid, medical providers are relentless and only send to collections as a last resort. Collections costs the provider money.

I understand that I'm responsible for my medical charges. When I went to the hospital, I had to stay for 24 hours for more testing, so I had a pretty substantial bill. I received my bills, after paying my deductible, and my 20%, my out of pocket expenses were met. The only thing that wasn't paid was the ambulance and that was due to the wrong coding on the bill. I had a PPO with Cigna, and according to my insurance benefits the ambulance was suppose to be paid . I guess I didn't make myself clear on receiving a bill, I did receive a bill from the ambulance company at the time of the appeal and I actually spoke with them when I won the appeal and they said that they talked to Cigna and Cigna told them they were going to pay the bill, from that point, I'm not sure what happen. I actually received a bill a couple of months ago from the ambulance company, but that was the first one that I received since March of 2015. For some reason, Cigna never sent me anything saying what they paid and what I was responsible for. I've talked to several people at Cigna and they are having a difficult time figuring out why a proof of an EOB was never sent to me till now. I'm good about paying my bills, as well as keeping all my medical information. I've always had good credit and I worked hard at it. If I knew that bill wasn't paid, I definitely would of looked into it further and taken responsibility for my part. Thank you for your time.