OT - Disputing a medical bill

[savannahcat]

I'll try to keep this short:

A few weeks ago, I pulled a tendon in my wrist and was prescribed a wrist splint that I was fitted for and received in my doctor's office. Today, I received a bill from the rehab company (not the doctor) for the splint in the amount of $172. They actually billed my insurance company $230. The discount amount was $58, leaving me with the difference. Unfortunately, I have a $200 deductible for these types of items.

Thinking that this total was more than it should be, I researched the splint online and found several sources selling the exact same item for anywhere from $22-$28 (and as low as $13 if purchased in quantity). I called the rehab company hoping to negotiate a reduced amount with no success, even after speaking to several employees up and down the management chain. They are more willing to let the invoice go to collection than to take a partial payment.

Here's my question: Is there something else I can do? What effect will defaulting on the payment have on my credit score (which is very good - 780+ right now)? I always try to do the right thing and pay what I owe, but I refuse to pay 8 times what an item is worth on the retail market. Am I wrong?

Thanks for your help!

 

[msmayor]

I'll try to keep this short:

A few weeks ago, I pulled a tendon in my wrist and was prescribed a wrist splint that I was fitted for and received in my doctor's office. Today, I received a bill from the rehab company (not the doctor) for the splint in the amount of $172. They actually billed my insurance company $230. The discount amount was $58, leaving me with the difference. Unfortunately, I have a $200 deductible for these types of items.

Thinking that this total was more than it should be, I researched the splint online and found several sources selling the exact same item for anywhere from $22-$28 (and as low as $13 if purchased in quantity). I called the rehab company hoping to negotiate a reduced amount with no success, even after speaking to several employees up and down the management chain. They are more willing to let the invoice go to collection than to take a partial payment.

Here's my question: Is there something else I can do? What effect will defaulting on the payment have on my credit score (which is very good - 780+ right now)? I always try to do the right thing and pay what I owe, but I refuse to pay 8 times what an item is worth on the retail market. Am I wrong?

Thanks for your help!

You indicate that you not only received 'a' splint, but one that was fitted to your wrist and received in your Doctor's office. That's more than just buying one off the shelf in the retail market.

Pay the bill, and let it be a lesson to you. Before agreeing to receive durable medical equipment through the doctor ask about whether you can obtain one on your own to save money.

 

[savannahcat]

You indicate that you not only received 'a' splint, but one that was fitted to your wrist and received in your Doctor's office. That's more than just buying one off the shelf in the retail market.

Pay the bill, and let it be a lesson to you. Before agreeing to receive durable medical equipment through the doctor ask about whether you can obtain one on your own to save money.

You can bet I will ask this question the next time! I think I should be more clear about the fitting though - the assistant looked at my wrist, pulled a splint from the shelf, and had me put it on to make sure it fit. There was nothing custom about it.

 

[NotUrsula]

I'd go back to your insurance company and check on what kind of agreement the provider has with them.

If this is an in-network agreement, the provider is supposed to only bill what is reasonable and customary for the item; if they billed WAY over what it was worth, it's no wonder that the insurance company refused to pay that. If the provider is in-network, they may have an agreement that they have to settle for X amount, and they are usually prohibited by the contract from trying to get the difference directly from the patient. I've got a dentist who ALWAYS tries to get the difference directly out of me; I've reported him to the insurance company several times for it. (I'm looking to change dentists right now for that reason, but haven't found anyone else that works for us yet.)

PS: In the past, medical debts normally didn't count against credit scores, but that's changing now; physicians are selling debt to collections agencies just like everyone else.

 

[bumbershoot]

Just pay it. This isn't worth it. I'm not saying it's not a large amount of money, but this is nothing new. Ever been hospitalized? Get an itemized bill and see what they charge for Tylenol (it was $15 per pill after my friend's recent liver transplant, once she was on simple things like tylenol). This is common.

 

[mjkacmom]

When my ds got a splint, I had to sign a form stating that if my insurance didn't cover the cost, I would have to pay the balance to the splint company myself. I was so happy not to get a bill!

 

[savannahcat]

When my ds got a splint, I had to sign a form stating that if my insurance didn't cover the cost, I would have to pay the balance to the splint company myself. I was so happy not to get a bill!

Would you mind if I ask what the company charged for your DS's splint? I have so much trouble believing that $172 is reasonable and customary.

 

[ajk912]

Oh gosh, that durable medical equipment stuff is PRICEY. After I broke my back I had a soft cast. They billed TWO THOUSAND DOLLARS. My portion was about $400, 80%.

My daughter has sciolosis, and I am expecting a similiar bill for when she gets her soft cast redone.

 

[pdchris]

Just pay it. This isn't worth it. I'm not saying it's not a large amount of money, but this is nothing new. Ever been hospitalized? Get an itemized bill and see what they charge for Tylenol (it was $15 per pill after my friend's recent liver transplant, once she was on simple things like tylenol). This is common.

/rant on
Well, if Medicare and Medicaid would actually pay, at the minimum, the cost to the hospital people wouldn't be charged so much. I'm not saying it's right, most definitely not.
However, how many people are aware that Medicaid (I forget the Medicare %) only pays 80% of the cost to the provider? It's like walking into a grocery store to get a loaf of bread. The cashier says, "$1.50." To which you reply, "I"ll only pay you ninety cents." And you HAVE to accept it.
And take a look at medical equipment companies. Nobody talks about the ridiculous prices they charge providers for equipment.
The fact is, when selling to a hospital, whether for-profit or not-for-profit, they really jack the prices up.
(OTOH, what some so-called not-for-profit hospitals pay their CEO's is obscene.)
/rant off

 

[savannahcat]

And take a look at medical equipment companies. Nobody talks about the ridiculous prices they charge providers for equipment.
The fact is, when selling to a hospital, whether for-profit or not-for-profit, they really jack the prices up.

This is exactly what I'm dealing with. This is a medical equipment company billing me a ridiculous amount of money just because I got the splint at the doctor's office and not at the Walmart.

I did discover that my DH's current benefit handbook states that in-network durable medical goods are to be paid at 100% with no deductible, so I'll be appealing the invoice with the insurance company tomorrow.

 

[Avonlady1001]

If you think it's worth fighting for, fight it.

When I had my son this past October, they did a hearing test in the hospital, without my knowledge or permission. They said after it was mandatory. My insurance paid a mere $80 of the $400 bill. They said I was responsible for the rest. I did some research (like you) and found that 1. test is not mandatory IN the hospital. But it does have to be done...I could have gotten a Rx for it & had it done elsewhere; 2. they were required to get my permission first...not hand me the form to sign after...which I did; 3. the test should cost no more than $90 (so why $400???).

I contacted the NYS Dept of Health & said I wanted to file a complaint against the company & the hospital AND that I thought the law should be changed so the insurance company is REQUIRED to pay for a MANDATORY test.

The Dept of Health called me back. I was not the first to complain...and they were doing some things & she'd get back to me. I thought that was the last I would hear. WELL, she called back & gave me the # to a hospital admin. I called him & he said he would take care of it w/ the hearing test company. My balance is now 0.

SO FIGHT FIGHT FIGHT. I fight ALL my bills now. You may not win, but at least you tried.

 

[mjkacmom]

Would you mind if I ask what the company charged for your DS's splint? I have so much trouble believing that $172 is reasonable and customary.

I never got a bill, so I assume my insurance company paid (although it was only a couple of months ago). I think you need to go after your insurance company - why can't the doctor just order a bunch?! I was very nervous signing that paper.

 

[savannahcat]

If you think it's worth fighting for, fight it.

When I had my son this past October, they did a hearing test in the hospital, without my knowledge or permission. They said after it was mandatory. My insurance paid a mere $80 of the $400 bill. They said I was responsible for the rest. I did some research (like you) and found that 1. test is not mandatory IN the hospital. But it does have to be done...I could have gotten a Rx for it & had it done elsewhere; 2. they were required to get my permission first...not hand me the form to sign after...which I did; 3. the test should cost no more than $90 (so why $400???).

I contacted the NYS Dept of Health & said I wanted to file a complaint against the company & the hospital AND that I thought the law should be changed so the insurance company is REQUIRED to pay for a MANDATORY test.

The Dept of Health called me back. I was not the first to complain...and they were doing some things & she'd get back to me. I thought that was the last I would hear. WELL, she called back & gave me the # to a hospital admin. I called him & he said he would take care of it w/ the hearing test company. My balance is now 0.

SO FIGHT FIGHT FIGHT. I fight ALL my bills now. You may not win, but at least you tried.

Thanks for the pep talk - I really needed it! It's not the money - I could certainly pay the bill in full today if I chose to, but it's the principal of the matter. I think this kind of thing continues to go on because people don't fight in these instances - especially when the amount is relatively small and it seems like a lot of work for what may amount to nothing.

 

[mousefan1972]

This is exactly what I'm dealing with. This is a medical equipment company billing me a ridiculous amount of money just because I got the splint at the doctor's office and not at the Walmart.

I did discover that my DH's current benefit handbook states that in-network durable medical goods are to be paid at 100% with no deductible, so I'll be appealing the invoice with the insurance company tomorrow.

What might have happened, though, is the splint might not be considered DME because it is an "off the shelf" one and not a custom fit one. (I am a physical therapist) Definitely try it, though, and add that the doctor's office did not give you the option to buy it elsewhere. We only do custom splints at my company for this very reason; most insurances consider them DME. Good luck!

Edited to add: Also have the doctor's office write an actual prescription for the splint, and fax it to the insurance co.

 

[pdchris]

This is exactly what I'm dealing with. This is a medical equipment company billing me a ridiculous amount of money just because I got the splint at the doctor's office and not at the Walmart.

I did discover that my DH's current benefit handbook states that in-network durable medical goods are to be paid at 100% with no deductible, so I'll be appealing the invoice with the insurance company tomorrow.

Good for you. That's a load of crap they're giving you. If it's in the handbook, they sure as heck know about it.

 

[Lewisc]

You didn't indicate your insurance company or what state you live in.

Insurance companies generally negotiate good discounts with providers in their network. The rehab company billed $230 but the negotiated discounted bill was $172. Most insurance companies won't allow 172 if a significantly lower price is justified.

Presumably this bill didn't just include the cost of the split but professional services necessary to fit the splint.

Not surprised the company isn't willing to further discount the bill.

You haven't met your deductible. I'd pay the bill.

 

[savannahcat]

You didn't indicate your insurance company or what state you live in.

Insurance companies generally negotiate good discounts with providers in their network. The rehab company billed $230 but the negotiated discounted bill was $172. Most insurance companies won't allow 172 if a significantly lower price is justified.

Presumably this bill didn't just include the cost of the split but professional services necessary to fit the splint.

Not surprised the company isn't willing to further discount the bill.

You haven't met your deductible. I'd pay the bill.

I would agree, but for two things:

1) According to my insurance handbook, I have no deductible. The CS rep on the phone says I do, but the current handbook says otherwise.

2) The person who fit the splint is employed by my doctor's office. The bill is from the medical supply company. My doctor is a personal friend, so I know the professional services to fit the splint were billed as part of the office visit, not by the medical supply company. My doctor finds the charge ridiculous as well and will be writing a statement as part of my appeal.

Ironically, I had the option to have a cast on my wrist which my insurance would have paid for in full. One reason my doctor and I decided on the splint was because we thought it would be more cost effective.

 

[WDWorBUST]

Another thing to consider....and I know it's a reach.....but people at insurance companies make mistakes too. The people in customer service and processing claims have training....but not to the extent that you would think that they would. Also....ridiculous or not the "discounted" rate was the $172. The one thing I agree with 100% is to appeal it with your insurance company....but I wouldn't not pay it if you don't win. Also....and this isn't directed at YOU....but if it has been more than a year since your DH has been with the company he is with it is not uncommon for new Summary Plan Descriptions to be given that never make it home....the mysteriously disappear into the "Twilight Zone" - it is definitely a very scary phenomenon. It isn't uncommon not to change carriers but for their to be plan changes with the same carrier.

Also...whoever said it had been a couple of months and no bill - you might not be in the clear. I had a procedure done 4/16 and the anesthesiologist hasn't even filed the claim yet and when I called them about it they didn't even show me in their system and couldn't do anything until then. Who knows how long it will be before I find out how much I owe the anesthesiologist.

 

[bumbershoot]

/rant on
Well, if Medicare and Medicaid would actually pay, at the minimum, the cost to the hospital people wouldn't be charged so much. I'm not saying it's right, most definitely not.
However, how many people are aware that Medicaid (I forget the Medicare %) only pays 80% of the cost to the provider? It's like walking into a grocery store to get a loaf of bread. The cashier says, "$1.50." To which you reply, "I"ll only pay you ninety cents." And you HAVE to accept it.
And take a look at medical equipment companies. Nobody talks about the ridiculous prices they charge providers for equipment.
The fact is, when selling to a hospital, whether for-profit or not-for-profit, they really jack the prices up.
(OTOH, what some so-called not-for-profit hospitals pay their CEO's is obscene.)
/rant off

ITA. But that's a battle that will be won with the utter dissolution of all insurance companies. Which will happen, oh, never.

My chiro is now getting reimbursed by insurance LESS than I was reimbursed (or rather my patients, b/c I refused to bill insurance and was paid directly by my patients) when I was in practice between '95 and '00. That's NOT right. But providers just play the game along wiht the insurance companies...they know they'll pay 80% of a certain amount? They bill the exact amount that gets them the amount they want.

IThe bill is from the medical supply company. ....the professional services to fit the splint were billed as part of the office visit, not by the medical supply company.

Then why on earth is the supply company charging YOU? Shouldn't this be charged by the MD's office? It's very confusing.


I'm all about fighting the system, but with this sort fo thing, unless there's been an actual mistake, you likely won't win.

 

[Tweevil]

You have received a lot of great suggestions in this thread.

I just wanted to add that the hospital reimb for Medicare is around 13% and Medicaid is around 11% of total gross charges in my neck of the woods. That is sad because it forces suppliers/providers to set their cost to charge ratio atronomically higher to accomodate the actual cost of the supplies, drugs, etc. This is why many people get sticker shock when they ask for an itemized bill - it truly is sad...

You don't reference what state you are in but there are legislative changes making their way around. For example in NJ effect Feb 1, 2009 (I believe) if you are uninsured hospitals have to bill you a reduced rate that is comparable to the Medicare DRG/APC rates with a small increase allowed - say 115% of what Medicare would pay. A lot of providers are extending this out to under-insured people (anyone who cannot pay a larger deduct etc.) and it is proving to be a tough transition but it is a nice one for those who do not qualify for financial assistance.

I do agree that the squeaky wheel gets the grease - and you should go forward with your dispute. Challenge your insurance carrier if your plan benefit book says DME is covered at 100%, they do make mistakes and trust me it happens all the time. Especially some of the larger ins plans have multiple systems that do not "talk" to each other. Also, while you are on the phone with your insurance carrier ask them if their contract with the DME provider stipulates that they cannot reduced patient responsibility. In some cases contracts between insurance companies and providers have verbiage that state the provider cannot discount what is dictated to them. If this is the case the DME provider can't do it anyway. If they do and are found to have done it they would be in violation with the insurance carrier and can be kicked out of network. That could potentially kill their business if the insurance has a large market share in the area. If this is the case it is a probably a done deal because the DME provider just can't do it.

If your insurance did correctly process the claim per your benefits, the next step would be to ask the DME provider for an itemized bill or call and obtain the CPT code is for the splint, go into the CMS website and get a round about of how much Medicare would pay (your doc can help with this if you ask) and then offer that to them either on the phone with a supervisor or in writing. If they decline unfortunately you may have to pay to protect your credit score.

Just keep in mind that accessing healthcare today is more of a consumer driven market than ever before. With the introduction of HSA's and things of that nature, providers are being asked for charges upfront as well as a discount rate before people even come in the door.

I hope all works out well for you, just continue to question the charge, how it was adjudicated, and what the DME is going to do for you.

Sorry for the rambling but this is all too common for me to handle on a daily basis and I thought perhaps this info could arm you with good info to dispute with.