Hospital bill not covered?

Question

I have full Horoizon HMO insurance (which I pay 400 a month for). I went to the ER and was admitted for major stomach pain in which the checked my appendix but I was OK. They released me, and that was that.

I got the statement from the insurance co today saying not covered is 16k of the 19k bill. Now my PCP sent me to the hospital and approved to have me admitted. They took all my insurance info. Is this just some BS or would I have to pay a 16k bill when im supposed to be 100% insured?

Answer 1

Most likely it is either a billing error or you're misunderstanding the statement.

In the first situation (billing error) - its possible that your PCP's referral crossed paths with the hospital's claim. If the referral wasn't in the system yet, it might have kicked out your claim in error. This situation should be fairly easily resolved with a phone call or two.

In the second situation (misunderstanding statement), the hospital might have an agreement with the insurance company to accept $3K on the bill and write off the rest of the charge. It doesn't mean that you're liable for the $16K - the hospital writes that off.

You need to clarify what's going on, and then it should be fairly easy to resolve. (As long as you were referred by your PCP and you went to a hospital that participates w/your HMO plan.)

Answer 2

You need to first find out WHY the bill was denied. That makes a big difference.

If it was denied for no authorization from your PCP or the hospital - that's easy enough to fix. You call your PCP or the hospital's billing department and they call your insurance.

If it was denied for being out of network, try appealing - if your doctor can back you up on that it was URGENT you be seen, most likely the insurance will relent.

Most times, a denial can be reversed, you need to not back down when you get a run around.

Answer 3

Great question. They should have given you a REASON why they're declining to pay. What's the REASON? Or did they "reprice" down to $3K? in which case NO ONE pays the $16K . . .

Answer 4

Sounds like a mistake. Call them and ask them why they are not paying the bill.

Answer 5

sound like a mistake to me. even with co-pay the reverse should be right amount.