Hi Heather - I feel your pain. I do medical billing for a living and UHC is one of the quickest to pay the doctors, but also one of the WORST as far as paying correctly. I would not give up on appealing, but I would also send a copy to the state insurance commissioner. It would also help if had documented the person's name who told you that you were in network. I ALWAYS document names and time of day that I spoke with someone. It really gives you a little more clout when trying to set somewhere with the insurance company.

Don't feel to bad; I have a $10,000 deductible. :(
and my dh broke his wrist TWO days before the new year started. Just got the EOB yesterday......$1,500!!! And the doctor was in the room a total of 4 minutes. Yes, I timed it! Good luck with your appeal.

I had to appeal once, and argue, the clinic doctor wanted us to see a sepcific ortho, who HAPPENED to be in the ER at the time. So that's where we went. I argued that bill for like $15...I don't know if I convinced them that I wouldn't have been there if it wasn't where my Dr wanted me to see the specialist, or if it wasn't worth their time. BUT I did win.

That said, it is NOT the hospital's responsibility to make sure YOUR insurance is one of the insurances their hospital covered, that is yours, and you should have looked that up when you moved (sorry, I know it's a pain, but if we're traveling or anything I look to see what's covered under insurance, just in case as ours is picky too). And now days when you can easily go on line usually to find who's covered...

So..why would the ER doctor be covered if the ER visit isn't? I don't know that ER doctors work at different hospitals. THAT would be my question, and the basis for my appeal. That sounds more like you maybe have a high deductible for an ER visit that wasn't met? Things to reasearch on your insurance. Have all your ducks in a row, and call billing again. Get those questions answered and you will know if it's worth appealing.

And yes I also won when they wouldn't pay for a bill from "Health East St. XXX" hospital because they billed under "St. XXX Health East". THat took like 3 hours on the phone before I could convince everyone IT'S THE SAME HOSPITAL.

Vickey-MN

And people wonder why we need a Health Reform bill?

It's an all too common scam by hospitals.
The hospital is IN network, but certain departments and/or doctors there work for another corporation and does not negotiate rates to be IN network.
The non-network entities are owned by the hospital or a third corporation owns both.

Call the hospital billing dept and tell them you are reporting their misrepresentation to the your state Insurance commission, and to the Insurance company itself...unless the forgive the bill.

I've done it...it works.

I was going to reiterate that just because a hospital/facility is in network, it doesn't mean all the doctors are! Someone in our town had a surgery and the hospital and the surgeon were in network, but the anesthesiologist wasn't!!! How crazy is that? A person shouldn't have to go to those lengths to cover their bases.

It has to be understood that the insurance company is just the administrator of a plan, in many instances. Different employers may have VERY different plans, different lists of included drs and hospitals. You really do have to know YOUR specific plan. In my husband's case, his company is large--one of the largest employers in the nation--and they write their own rules. THEN they hire a healthcare insurance company to administer THEIR plan. It's not necessarily the same as other plans with the same company. For example--my aunt has UHC as her medicare supplemental insurance. They're fantastic, pay EVERYTHING that's left after medicare pays. But when we had UHC as DH's insurance, we were always getting turned down, and having to fight to get anything at all paid (we've since chosen a different company on the list and have had better luck with them).

Yes, it's worth fighting--keep doing it until you have no more levels to fight. Contact your state insurance commission. Once, when we had a problem with health insurance that we were having problems resolving, DH in frustration, contacted our state assemblyman--and HE got it resolved in our favor. Leave no stone unturned in your fight. And, if in the end, you are told you owe the bill, go back to the hospital's billing dept. and tell them you can't afford it--90% of the time they reduce the bill. I'm surprised they haven't already offered you a discount. Last time I was in the hospital, we got a bill. DH called to ask a question about paying, but NOT complaining about the price--and they offered HIM a significant discount (it was something like 1/3 of the bill!) You rarely have to pay the full bill if you kick up even the smallest fuss. They're generally glad to get anything, since so many simply don't pay at all.

Good luck. And once you get this all sorted and the dust has settled, sit down, go through your insurance paperwork, make a few calls, and verify exactly where and how your insurance can be used in future. Better to do that before you're in the throes of an emergency--even a minor one. Good luck

Oh...and contact your insurance company to tell them that that hospital is mis-representing their ER as being in-network for your insurance company.

One thing you might try is to contact your employer's HR/Benefits department. Tell them you are having issues with the insurance provider and ask them if they have a contact number for a UHC plan administrator for your group, who can help you navigate through this issue.

Not all companies have this level of support, but it's worth a phone call to find out.

I have to take exception to Monica's assertion that this is often a scam by the hospital. I can't even fathom how a hospital would implement such a thing.... Those who would "work it" would have to know ALL the "ins & outs" of each & every insurance co. as well as the the different variations within the various policies they offer, to say nothing of the ins. co. simply being the administrator of those who have "company" plans. THEN, these scammers would have to plot how they're going to "misrepresent". So, NO, don't believe this or any hospital has such a "scam". And further, there's no way a hospital operator, on the weekend, could possibly know all the ifs, ands, or buts of each & every insurance company's idiosyncrasies. They look in a data base & give the best answer they can. If anything, I think it's an example of the tactics the insurance companies employ methods to NOT pay.... (they skipped telling you the importance of using the word "railroad"... heh!)

Back to the question,,,, if all of your contact & discussions have thus far been over the phone, then you haven't exhausted your appeal rights and it is probably more of a "low level" decision rather than an actual ruling by those who have more power & probably knownledge/clinical expertise. So yes write out your appeal. I would NOT mention, nor use as part of the appeal, the fact that the dr was paid. (Maybe that was an erroneous payment(?) & you should let that sleeping dog lie.)

You should call the hospital's billing dept & explain the situation (that you are appealing & why, etc) & they will put a note on your bill so that you won't be deemed "late" or "non responsive". Keep them in the information loop.

You may have more than one level of appeal, & you should exhaust them all. If it all fails, then speak to the hospital billing dept. about negotiating the bill to a lower price. This happens more than you would expect. They WILL work with you, I believe. Hospitals are not in the business to scam people.

And as someone else said above..... we need health reform and this is a tiny example of WHY!!

Just to be sure, I called that hospital and asked if my insurance was in their network. We have United Health Care. So my question was "I have United Health Care. If I would bring my son to your emergency room would he be in network there?" The operator looked it up and said "Yes, your insurance is an in network provider with our hospital." So I took him there.

hmmm...Could there be some miscommunication here? I would be expecting an answer of "Yes, our hospital is in the preferred provider with United Health Care."

I took what they said as, "yes, we accept United Health Care INS", as I think not all insurances are accepted. I think if insurance is not accepted, that payment is expected up front and then that they 'might' file the insurance for you or you might have to file yourself to recoup your outlay.

Sue...just thinking out loud here

WOW!
Just as I expected, I got a LOT of helpful information from the ladies at the KT!

I thought that I knew a lot about this sort of thing, obviously I don't. I had never ever heard about the state insurance commission before. I had no idea that anything like that even existed.

I have already called the hospital and explained things to them. While doing that, AGAIN, they said that they were in network. Like I said, I know they were a few years ago but I know that it changes a lot as well.

And during one of my many calls to UHC, someone said to me "You do NOT need to say FOR RAILROAD, you have never had to do that and I'm not sure why anyone would have told you that."

I haven't written down names and dates of all of the different phone calls. I wish so badly that I would have now. From now on, that will be something that I do with all phone calls that I make as I have found myself wishing I'd have done that many different times now.

I will continue to fight this then, and I will appeal it. I feel a lot better about it after reading your responses.

THANK YOU for ALL of this extremely helpful information!! :)

Oh, also, have you checked on line to see what info is given for your UHC as to this hospital being in network? If their website addresses you situation/question, use that info in your appeal, also.

Isn't that interesting that one UHC person would tell you to use the term RAILROAD & another person would contradict that??
That's what I've found so frustrating & maddening...... that basically some people just talk out their a$$ & or just flat out lie!!! When I start to feel like I am getting the run around, or no where, then I ask to speak to a supervisor or sometimes a person with clinical background.

Definitely keep a journal whenever you're dealing with insurances, hospitals, dr's offices, billing agents etc with dates, times, names. This kind of thing can take time to resolve & you'll forget exactly what you asked & what they answered. (Voice of experience, here. LOL) Sometimes on later occasions you can cut to the chase & ASK for the person by name who has helped you in the past.

I have to take exception to Monica's assertion that this is often a scam by the hospital.

From a Medicare fraud auditor, a few years ago. I happened to mention I had a problem with a hospital bill, almost idential to the OP's. The auditor told me how it worked. When I called the hospital in question and told them I was going to report them, within hours the bill was "forgiven".