Sleezy Insurance company - headaches!

Ok I had temp insurance that I got back in Jan. Well in Feb I went to have a physical so that I could have a dr out here if I got sick (took 5 months to get the appt) well 2 DAYS after I saw her I got really sick - and ended up in the hospital. They can't believe that there was NO way I didn't have it when I went to see the Dr the other day (so dr probably missed it or they thought maybe I caught it then at best - which means she probably gave it to me - it was a severe ear infection with celluities etc)

Ok Well fast forward to present -

I get 2 letters (from this company they paid to review my records) last week saying that Insurance co sent my bills to them and that they reviewed it and determined what they felt was a fair payment (3K of the 5500 bill and the second letter said they paid 1300 of the 2500 bill) the letter says this is all that they will pay and that the hospital MIGHT come after me for the money. I have a $500 deduct and then they are to pay 100% I have already paid the deductable.

Today I get a stack of bills FROM the insurance co telling me to PAY almost 2,500 in bills to the hosptial (basically the AMOUNT that they are refusing to pay the hospital - and then listing on the bills that they have paid 100% and that this is the difference.

Basically they are saying that they paid the amount the company determined was a reasonable amount and so that is what they determine to be 100% of the bills - anything past that is the patients responsibility.

I don't quite get what they did but sounds like they're giving you the run around??? Insurance co's are the worst.

I hope you're feeling better You might have caught the ear inf. and celluitis in the waiting room.

I think you lost me a little there.. and I work for an Insurance Broker (not a company)

Sounds almost like most dental insurances work. They pay what they consider reasonable and the rest is up to the patient even AFTER deductible. We figured this out because Nightguards to help Jim stop grinding his teeth flat and for my TMJ is not 'reasonable' and we have to pay out of pocket.

I've never really heard of it for health unless it was outside their network.

Temporary Insurance? Is that what you said? Either way, I'd fight it. Worst comes to worse, you'd still have to pay, but it's always worth a chance.

Xelindrya - I think you might work for Marsh?

Anyway - yes it is a temp insurance - the kind you have for say 30 days to 6 months - meant to give you med insurance for a temp basis - DH and I planned on getting joint insurance so I just wanted something for like 3-4 months until we were married when my old insurance ran out since I am not working now.

It is confusing you have to look at the almost 50 pages of bills and letters to fully understand the garbage. First THEY HAVE NO IDEA how to do medical billing out here - NO ONES bills make any sense. Mom and Dh have NEVER seen bills like this before (they worked in med mal)

Anyway - they are supposed to cover all expenses according to my policy (that fall under covered charges and these clearly do) as they fall under hospitalization and all charges associated are covered 100% according to my policy - once you pay the $500 deductible.

Well the deductible has been met but
what they actually paid was the 100% OF WHAT THEY determined it to cost -which is about 50% of the total bill.

My insurance used a separate company who reviewed my record and said we think they over billed and will only pay X amount (about 3k on a 5500 part of the bill and 1300 on a 2600 bill) they sent me two letters saying this is what we determined to be the proper amount for your services and all that we will pay. We sent a check to the hospital and it is up to them whether they will accept it or not - if they won't they can come after you for the remainder of the money but we have paid them in full as far as we are concerned.

Then today I get 7 bills in one envelope saying - we paid X amount paid at 100% and you owe the hospital X amount (the remained of the FULL amount billed by the hospital). So they are basically telling me I owe the hospital 2-3K

I know it will work out but it is SUCH a headache - nevermind the fact that I probably got it from a dr's negligence AND then the hospital I was at didn't treat me aggressively enough right away and caused it to be worse than it should have been.