Surprise Billing, Part II

Let’s set the scene …

You have spent some time in the hospital, had a serious illness, and you receive excellent care, so you are able to come home. It takes a few days but you start feeling back to your normal. As you begin to exhale and get immersed in your life again, you receive a large bill.

Here’s an example of one that I received after a hospital stay:

After the initial reaction of astonishment and probably a small amount of panic, it’s time to figure out what to do. In this post, I will share my process and the applicable law in Florida to these issues. I am only licensed as an attorney in Florida but a quick google search should arm you with the applicable statutes in your state or feel free to contact me and I can walk you through it!

So, back to my process.

When I get a bill like this, I first look at my Explanations of Benefits (EOBs). These are the documents that I receive from my insurance company when they have paid a bill. EOBs are how we patients know the insurance company did something. I used to get everything in the mail and staple each EOB to the physical bill. This helped a LOT with organization when I was first diagnosed and overwhelmed. Now that I have a better handle on things, pretty much everything is electronic and saved in a folder for future review, if necessary. I then purge on a yearly basis.

Secondly, if there is an EOB, then that means the provider billed the insurance company and there is a response. If the response is that the provider is not covered, then the EOB will usually say that the entire or the majority of the bill is the patient’s responsibility. If there is no EOB, then the provider likely didn’t even bother to send the bill in. Once you know whether or not you have an EOB, then you can call your insurance company. I always call my insurance company to review bills before I call the provider and when they give me any answer, I make them tell me where in my insurance policy language is the authority for their position. Most of the time, I get a summary of the language that I then compare to the actual language. I don’t know who is writing these summaries but most of the ones I received have had at least one thing that is contradictory to my policy language.

Yes, I have most of the applicable parts of my policy highlighted, tagged and virtually memorized. It’s not necessary to memorize your coverage but when you have to review it as often as I have, it’s rather like a by product of familiarity. Knowing what your contract says is important.

I have Blue Cross Blue Shield of Alabama through my husband’s employment. Since his company is headquartered in Alabama, that’s the policy we have access to. So, for us, the bills flow through Florida Blue (aka Blue Cross Blue Shield of Florida) before they get to Alabama. This can get complicated but knowing this path of the bill can be helpful. For instance, the only way a provider is covered is if they are registered with Florida Blue, NOT BCBS of Alabama.

While I have private insurance, these steps apply to any public or federal benefits as well. I had the same conversations with Medicare for my father in law over the last decade or so that I have with my private insurance company and for nearly identical issues.

Third, once I have a handle on whether or not the bill is covered under my insurance and at what percentage, then I look at the mechanics of how the billed services were rendered. In the example I’m using with the bill above, the hospital sent out my bloodwork to the provider that sent me the bill. I wasn’t asked or consulted about where my bloodwork was sent. If they’d asked, I could have told them that the entity isn’t covered by BCBS. I know this because this is not the first time the same company has sent me a large bill, never billed my insurance company and then was aggressive at trying to collect funds I didn’t owe.

Fourth, I look to the Florida statutes to review my responsibility as a patient. In Florida, if a covered entity (meaning a hospital or clinic who is a covered provider on your insurance), then contracts with an individual or clinic who is not covered, then the patient isn’t responsible. It’s super simple, if the decision is not yours as to which provider or vendor is selected, then you don’t have to pay. However, if you do know or have a choice, then you may lose that protection. As of my last research, 42 states have some legislation that protects patients from getting these surprise bills where a patient has no way to know a bill will be sent. In Florida, if the entity knows that the patient does not have to pay and yet a bill is sent anyway, the entity is fined.

In my case, the non covered entity is quite well aware that they aren’t on my insurance. You can see from the bill above that they didn’t even bother to send the bill to my insurance company and I never received an EOB. Each time I call, the person answering the phone is well aware that my insurance doesn’t cover their services AND that I have no legal liability for the bill. The responses I’ve received have literally been along the lines of … “well, we send them out because some people just pay it” and “sometimes your insurance company will send you some money to cover a portion of the bill.”

I’ve reported this company every time they call and I’ve reported their predatory and illegal billing practices to my cancer center and hospital network. I am hopeful that they may lose business. I am quite sure that many people pay these bills even if that is financially difficult because they just don’t know not to.

The only way a predatory entity like Comprehensive Pathology Associates stays in business is because people pay the bills without knowing they don’t have to. There are options, though, and I know lawyers who take on these cases at no cost to the patient. Don’t pay a bill when you don’t owe money and ask for help with addressing surprise billing!