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A Most Despicable Medical Billing Situation

Today’s video features a situation we dealt with several years ago and hope we never see again. We were contacted by a gentleman who became our client after a lengthy hospital stay for which he received a six-figure bill in spite of being covered by an individual Platinum Plan, the most comprehensive coverage one can buy as an individual.

How did this happen?

This client had suffered a serious bout of depression and was admitted via ambulance to an out-of-network hospital. His admission was considered a psychiatric emergency and coverage was never in dispute by either the hospital or his insurer, United Healthcare. Moreover, his mother, the closest relative, checked his mail regularly and received correspondence from United Healthcare stating that the stay would be covered.

We later learned that the Hospital and the insurer agreed to work on a single case arrangement on behalf of our client. The term describes a special agreement between a hospital and insurer which allows the insured to remain at an out-of-network hospital with the protection of his in-network benefits. Somewhere along the way, these discussions fell apart and with them our client’s protected status. We have to assume the hospital was unhappy with the payment they received, United Healthcare probably stood firm and thus the hospital billed our client a six-figure amount.

In our opinion, what should have happened if the hospital had properly handled this matter, is that once his condition stabilized, the hospital staff should have discussed with him that he was admitted on an emergency basis to an out-of-network hospital. He should have been given the option of transfer to an in-network hospital and at least informed of the discussions between the hospital and United Healthcare. At that point, even in an impaired state he could have sought help from a family member or from an organization like ours to verify that United Healthcare would indeed continue to cover his stay.

We know that there was no discussion with the patient because when we requested documentation of this discussion from hospital staff one of my employees received a voice mail message indicating essentially that “there was no documentation because there was no discussion.” Hospitals are large, bureaucratic organizations and we can’t know how such a large bill was generated for our client but it was unspeakably cruel to do so.

We intervened to strongly encourage United Healthcare to step up and protect their member, meaning negotiate the dispute regarding payment to closure with the hospital. In the end, they did and ironically, our client only owed $500 which was his in-network inpatient admission copayment. That may seem low for a lengthy stay but the plan design of a platinum plan provides for low out-of-pocket exposure in exchange for high premiums.

I recently spoke to this former client and am delighted to report that he is doing exceptionally well. He is a well-educated man having earned both a Ph.D. and law degree so has a great deal to offer to society. He has founded a successful non-profit which he currently runs.

As we’ve discussed before, always try to have someone to rely on when you are receiving acute medical services. Again, we are often not at our best when experiencing serious illness and emergency admissions to out-of-network hospitals can be particularly problematic.

We urge you to watch this video to see how bad such behavior can be. Thankfully, most staff in our non-profit hospital world would not tolerate a patient being treated in such an unthinkable way.