hospital sticks me with bill

[beisnj]

I recently called a hospital and asked if it accepted my insurance at its urgent care clinic. The hospital said it did.

I went to the clinic and got treated. After that, the hospital billed me in full because my insurance was not accepted at the hospital in question.

Upon questioning the hospital by e-mail, it admitted to its representative saying my insurance was accepted there, but the hospital also said it doesn't matter because it's my responsibility to check with my insurance company to see if the hospital is under my plan.

For future reference, I am willing to accept it is my responsibility to contact the insurance company. Call me naive, but at the time I honestly thought calling the hospital and getting an answer was a legitimate way to handle the issue.

That said, do I not have a legal theory for recovery? It seems to me that the hospital saying it accepted my insurance would be grounds for a detrimental reliance claim or a misrepresentation claim. I have insurance, so I wouldn't have gone to the hospital had it not told me it accepted my insurance.

Anyway, other people have told me my responsibility to ask the insurance company trumps the hospital's responsibility to not make false statements. Is that true?

 

[cbg]

This is something I learned when I worked for an insurance carrier.

If you ask any medical services provider if they "accept" any particular insurance, chances are they will say yes. What that question means to them is, if X insurance carrier sends you a check, will you accept it? Yes, they will - they will not come after the patient for that payment. (This arises from the days before managed care and participating providers when sometimes hospitals, doctors etc. would take payments directly from the insurance carriers and sometimes they would take payments only from the patient after the insurance company had sent the patient a check.)

What you need to ask is if the hospital is a participating provider on the X insurance company network. Additionally, when it comes to urgent care centers, laboratories, Radiology, Anesthesia, and a couple of other departments that are occasionally stand-alone centers using the hospital facilities, you need to ask if THAT PARTICULAR DEPARTMENT is a participating provider.

It seems like a minor distinction but it is not.

Believe me, both the insurance company and the hospital would love it if they could force all departments and all doctors working at a hospital to participate in the same networks, but they cannot - not legally.

 

[beisnj]

I specifically called the urgent care center in my original call, but I do not recall using the phrase "in-network".

I'm guessing that means it wouldn't be worth it for me to file a small claim, then?

I really think their comment on the phone is misrepresentation or causes detrimental reliance. Surely, they know or have reason to know what a caller is asking these days by that question.

And, if they had the good sense to know what question I was really asking after the visit it seems like they should have known what question I was asking before I went up there. They should have just told me up front, "Sorry, sir. You need to ask your insurance provider if the specific facility and doctor you are going to see are in-network."