Medical insurance contract dispute, hospital trying to make me pay full amount

[oc282]

Hi,

I was admitted to a hospital in California last September (2004) following an accident. The hospital bill came to almost $69000. My insurance (Aetna) sent a payment for $2775 indicating that is the contracted amount since the hospital is part of their preferred provider network. However, the hospital claims that the contract between them and Aetna was cancelled as of June 1st, 2004. Aetna admits the contract has been cancelled, but they say it was canncelled on December 31, 2004. Because of this the hospital is billing me for the balance ($65000) while Aetna will not accept an appeal because they claim they have already paid according to their contract with the hospital.

Aetna is not willing to provide me with written proof of their contract (they say it's confidential information), nor have they managed to convince the hospital that their contract was still valid at the time of service. Last I heard Aetna was considering filing a lawsuit against the hospital (it appears I am not the only patient in this situation).

However, the hospital is getting ready to send my account to a collection agency in 10 days from now (June 30th) unless I pay them 25% of the bill ($16229). With great sacrifice I could probably pay this amount using credit card balance transfers, but I there are several issues:

1) what if Aetna manages to prove through a lawsuit that their contract was still valid and that the hospital was not allowed to bill me for the balance of the billl (from $2775 to $68552). will I be able to recover my $16000 payment, or will I lose my rights because I settled ?

2) if I don't pay and they send me to collection, can I stop the collection action by providing the collection agency with a written statement from Aetna that they had that hospital as a contracted provider and they paid the contracted amount even though the hospital says otherwise ? (and even though I have no written proof of the validity of the contract in question ?)

3) is there any point in filing a lawsuit against either of these parties ? (Aetna or the hospital)

Thank you!

 

[lwpat]

Most states have a consumer advocate or insurance commission that may be able to help you with this situation. Start by going to the state webpage and looking for a link.

 

[annie70]

i am not a lawyer, but I have 14 years as an Insurance claims specialist with a private practice.
you're in a very unusual situation. So Aetna paid the PPO rate because they say that the Hospital was participating, but the hospital billed you for the balance because they said that they were non-par. Personally, I would contact the manager over the billing dept. at the hospital first...explain the situation to them and see if you can get any additional information. The hospital does have the ability resolve this situation..you just have to get in touch with someone who will actually do it. My own father was almost sent to collections because he couldn't get antyone in the billing dept to change his ins. info and refile his claims! (And we wonder why it costs $5 for an aspirin!)
I work for a surgeon..for a period of about 3 months, the hospital was billing patients for a drug the Dr. DID NOT USE....it was a glitch in their billing system..an experimental chemotherapy drug billed for an eye surgeon! We had several patiens receive hospital bills for this drug..2 concerned patients contacted our office because after several phone calls and guarantees from the billing reps the problem would be taken care of, thier accounts were getting ready to be sent to collections. I contacted the manager over the dept and the problem was finally resolved.
As far as Aetna is concerned, if your insurance is thru your employer, I would definitely have them call on your behalf...they tend to be a little more helpful if they are worried about losing thousands of dollars in premiums when an employer complains that their employees are having problems with their insurance claims..contact your HR dept and see if they can get Aetna to resolve the problem w/ the hospital. Also, if they do agree that the term date was in June, if your situation was emergent, the ins co will sometimes pay 100% of the billed charges because immediate care was necessary.

The bottom line is that the contract is between you and your insurance company. The hospital does have the right to bill you for the balance of the bill, and I strongly urge you to speak w/ someone higher up in the dept., if for nothing else, get them to put a hold on your acct for a few months until this mix up can be researched..If you do make any payments, you should be issued a refund from the hospital if Aetna does make an additional payment or if the hospital takes the contractual adjustments.

I also agree that you should contact the Insurance Commisioner for your state to register a complaint.

Good Luck!

 

[NYClex]

There are several legal issues here. The advice given above is very good, I would contact the state insurance commission and the contact person in your employer's HR department (some times called health care advocate etc.). Then I would closely review the paperwork you have from the hospital:

Did they accept your insurance information when you were admitted? Did anyone point out to you that they would not be in your insurance's network? Did you sign anything acknowledging that they would not take that insurance payment?

You probably are a so called third party beneficiary of the contract between the hospital and Aetna, so if the hospital breached the contract, you have legal standing to sue them.

Even if it should turn out that in fact the hospital cancelled the contract in July, there might be a way to prevail: when you can show that nobody informed you of that fact, that they took your insurance information and behaved as if they would be in the network. Under contract law, if you foreseeably relied on a promise, in this case here that the hospital would accept the insurance rates, they might be estopped to claim more.

So if you get insufficient answers you should probably consult an attorney because a lot of money is at stake here.

I just went through the same thing with a doctor and Aetna, he had cancelled the contract and not bothered to inform me or other patients about it and then sent a bill that was 5 times as high as I would have paid in network. We just settled this week. The amount was not worth the hassle going to court for, but in your case I would have gone. Aetna, on the other hand, was not really helpful at all.

 

[oc282]

Thank you for your replies. I have contacted the insurance comission in California and they got Aetna to issue a statement (but no further proof) that they paid according to their contract. This statement was to the satisfaction of the insurance comission and they refused to pursue the matter any further.

This was an emergency admission indeed and I had no say in where to be taken so Aetna should have taken care of the bill. But as I explained they are having a contract dispute with this hospital. I tried talking to somebody higher up at the hospital but it all came to the same point - they have requested written proof of the contract from Aetna and Aetna has not provided them with that written proof. I have a feeling that Aetna must be hiding something, or maybe both parties are hiding something. Unfortunately I can't pressure Aetna through the threat of losing the contract with my employer because they already lost it! Aetna ceased to be our health insurance provider about 10 days after my hospital admission. We switched to Pacificare.

So where the issue stands is that I got no useful help from the CA insurance comission, and Aetna is refusing to show me proof of that disputed contract. So when I talked to a lawyer I was told we'd probably have to sue both parties and start the discovery process - but if that process requires going to trial it would probably cost me more money than the $16000 settlement that they are offering me. Unfortunately 16000 is at the very limit of what I could spend on this matter, any additional expenses will probably force me to go through a messy Chapter 13 bankruptcy. So I'm trying hard to decide if I should risk it and let the debt go to collection while the legal matters are worked on or take the settlement and try to sue one of the parties once the contract dispute is cleared up and my finances recover a little bit. Tenet Healthcare (the owner of the hospital) did put the account on hold for a couple of months, but now says they are not willing to wait any longer in the absence of written proof of that contract, which written proof I am unable to obtain.

To answer NYClex's questions: I was admitted to the emergency room so we didn't get to talk about insurance until the morning of my third day in the hospital (which was also my last day) - at the time they took the information and made no comments. I believe I signed the standard patient financial responsibility form but I don't remember the details. They took the money the insurance has paid so far as partial payment and are balance billing me. I will try to talk to an attorney again about the "relying on the promise issue". Can anybody recommend a lawyer that has experience with this matters in Southern California ?