Corporate Crimefighters Newsletter

BLINDSIDED BY BILLS

http://www.abc15.com/content/news/investigators/story.aspx?content_id=89ce8383-7adc-4b2d-a5dc-d4470f6761ce

There are some videos a the link, so go there. (John Metz is one of our members.)

Blindsided by Bills

By Investigator Lisa Fletcher
ABC15.com

If you've ever been stuck with a medical bill you thought your insurance was going to pay but didn't, you can count yourself among millions in the same boat.

And it's a boat that's sinking fast.

It's estimated that nearly 60 percent of all bankruptcies are because of medical bills.

But what if the bill should have been paid by your insurance...but wasn't?

Or the hospital charged you a rate virtually no one pays, all because you didn't know what you were entitled to?

Most of the one-million Americans who went bankrupt because of medical bills last year were middle class homeowners who had medical insurance.

John Metz is the Executive Director of "Just Health," a non-profit that helps people who get taken advantage of by hospitals, doctors and insurance companies.

"An insurance company saying that they'll pay doesn't mean that they'll actually pay. It's a battle that's raging every day all across America and the vast majority of people don't understand that they've been wronged."

Charles Croston went in for a routine procedure.

He knew his providers were all under his insurance policy.

"But low and behold, they use a doctor who is not part of that system and he billed me separately and said I want $850."

Charles was never told the hospital could substitute his anesthesiologist with a doctor outside his plan.

He only figured it out on his way into surgery.

Metz says he's not surprised.

"He's been given anesthetic. He's about to fall asleep. What's he going to do exactly? It's my belief that the responsibility lies with the providers. They have a duty to inform the patient in advance because there's not equality in knowledge."

Here's what we discovered most people don't know:

Just because the hospital takes your insurance, doesn't mean you're covered.

Most hospitals contract with groups of doctors who are not their employees: Like anesthesiologists, radiologists and ER doctors.

Each can charge you separately for whatever amount they want.

Bryan Sharp injured his eye and needed emergency treatment.

"They accepted my insurance at the time that i checked in."

But by the time it was all said and done, Bryan had bills...not co-pays or deductibles...but bills - totaling more than $19,000.

Metz says it's a situation where providers are not being upfront with patients.

"If they wanna say look, you come to our hospital and we're going to squeeze every dime out of you that we can get. We're gonna charge you a million dollars for this stuff and if you don't like it, go somewhere else, well, at least that would be honest."

And if you don't have health insurance, or are caught in between having coverage, like Liz and Eric Kuhl - this gets so much worse. Metz says the results can be devastating.

"The consequences of not informing people, as you found in your own investigation, I see regularly, can be worse than the disease."

Not long ago, Eric went to the E.R. for kidney stones.

"I was just in really really excruciating pain."

One prescription, two CT scans and 45 minutes of treatment later he was back home.

Bills arrived.

Eric and his wife, Liz, paid them.

"The ER doctor, the hospital and a radiology service that read the CT scan."

But what they didn't expect was an enormous - and unitemized bill - from St. Joseph's Hospital - Catholic Healthcare West.

Remember - Eric says he was only there about an hour and already paid all the doctors.

"I was so shocked when we got the bill. I was just like - unbelievable. It was over five thousand dollars. Five grand!"

To make it worse, the Kuhl's say the hospital sent it to collections before the bill was even due.

John Metz says this wouldn't be the first time Catholic Heathcare West was accused of overbilling and this sort of conduct.

"Catholic Healthcare West was sued in California for virtually the same kind of conduct." "This stuff is just wrongful."

Determined to help, the Kuhl's were on the line as Metz dialed the top dogs at St. Joseph's.

First up, hospital president Linda Hunt.

Metz gets transferred three times trying to get her on the phone.

"Linda Hunt please." "I'm trying to get through to Linda Hunt." "I need to speak to Linda about this situation."

Plenty of talk but no action. Nobody will put John and the Kuhl's through to Linda Hunt. And each person he speaks to will not answer John's question: "If you won't transfer me to Linda, do you have full and unfettered authority to resolve this situation?"

Next up: the head of billing, Jack Chapman.

Chapman is terse and cuts the Kuhl's off mid-sentence while they're trying to explain the situation.

Chapman only wants the story in writing, so Metz jumps in. "You're not willing at this point to look at the situation?"

Chapman says he's going to terminate the call, and hangs up.

Finally - Metz calls the CEO of Catholic Healthcare West.

"I would like to speak to Lloyd Dean."

No luck and no Lloyd.But this time, the person on the phone seems willing to help. She takes down the pertinent information from John Metz and the Kuhl's and promises to pass the information along to Mr. Dean.

And it appears she just may have done that.

At the time of this story posting on ABC15.com, John Metz reports to us that Mr. Dean's office is in fact involved and that, as Metz says, "The ball is in the court of the guy where the buck stops."

Metz tells us that the CEO has indicated he's concerned. Metz and the Kuhl's have forwarded all of the paperwork that his office has requested.

We'll let you know how this one gets resolved...

John Metz says beware of "insider lingo."
Here are some words and phrases to know:


Usual and Customary Charges:  This is the charge that the doctor or hospital says it's "normal" for them to receive. It is also, generally, the so-called maximum agreed-upon amount that insurance companies say is "normal" for them to pay. Metz says the 'usual and cusomary charges' may be different between the hospital and insurance company.

Video Watch John Metz talk about usual and customary charges


Charge Master Rate: This is the rate that hospitals say that they charge everyone. Metz says this is the highest rate and the rate that typically nobody actually pays.

Video Watch John Metz talk about charging master rates

Ask questions ahead of time to confirm that your providers are under your plan. Know that the hospital may know more than you and not tell you.

Video Watch John Metz talk about asking questions ahead of time


 
If you were treated in an “in network” hospital by “out-of-network” doctors and now you are being billed by the doctor because your health insurance won’t pay that doctor…

Health Insurance Tips
Read your health insurance plan documents to learn how your contract covers in-network and out-of-network services.  Talk to your employer’s Human Resources office or contact the insurance company to get copies of your plan documents.

Call the insurance company Customer Service.  Ask for suggestions on how to avoid being billed by out-of-network doctors that treated you in an in-network hospital.

If you are admitted to the hospital, repeatedly tell the hospital staff that you want to be treated by providers that are contracted with your health plan (or ask a friend or family member to help you do this).

IMPORTANT:  If you have HMO coverage, the HMO cannot deny a non-contracted doctor bill from a contracted hospital as long as the service you received was covered!  Also, HMOs must cover emergency visits to a hospital emergency room regardless of whether the hospital is in-network or not.  Call the Arizona Department of Insurance for more information.

It pays to appeal health insurance denials.  Many insurers overturn more than 50% of the denied claims that are appealed.  Arizonans can appeal BOTH denied claim payments and denied services under all types of health insurance policies—dental, PPO, BCBS, HMO (there are different appeal rights for self-insured plans, Medicare, or Medicaid).  You have 2 years to appeal a denied claim and you can appeal denials based on either “not covered under policy” or “not medically necessary”.  For more information, click here.
Contact the Arizona Department of Insurance (ADOI):

Phone number: (602) 364-2499
Website: consumers@azinsurance.gov
Stop by 2910 N. 44th Street, 2nd Floor. 
The ADOI Consumer Affairs staff may be able to explain what options you may have.

Call the medical provider’s office to inquire about the billing.  Provider’s can grieve denied health insurance payments.  For more information, click here
Tips When Making an Appeal

•When your health insurer denies a claim or service, it must advise you of your right to appeal the denial.

•You or your doctor must initiate the appeal (to the insurance company).

•In your written appeal, include as much supporting documentation as possible to illustrate why you believe the denied service or claim is covered or is medically necessary.

•When filing an Expedited Medical Review, you must include the doctor’s written certification that delaying treatment will negatively impact your medical condition.

•You must first complete the 2 levels of the internal appeals process with your insurer (Informal Reconsideration and Formal Appeal) before you can request an External Independent Review (performed by the Arizona Department of Insurance)

•Call your insurer and request a “Health Care Appeals Information Packet”.  There may be variations in appeals procedures from company to company (and state to state), so refer to this packet for specific details regarding your insurer’s  appeals procedures.

•You have two years to file an appeal for a denied claim payment!