Ouch!! Insurance question!

[unavidanueva]

Ok, here's a weird one. Has anybody ever heard of something like this before?

I will be having my DS with Dr. Prachand at the University of Chicago hospital. I had my first consult on May 27 -- met with the nutritionist, psychologist, assistant surgeon, and Prachand himself, in his office in the medical office building -- not at the hospital.

The claim has been processed by my HMO. I am covered for the visit, they are in network, second tier, approved referral. But instead of the standard specialist co-pay, I was charged the $250 hospital visit (ER) copay, billed under the name of the children's hospital. I called the HMO to ask them to explain it. She said, I see that you visited the doctor and weren't admitted to the hospital, but they billed it as a hospital visit, so you'll have to call them to have them submit a corrected claim.

I called the doctor's office, and they sent my call to the billing department. The physician billing department has no record of me; they transferred me to the hospital billing department. They said, there is no way to "correct" the claim because the claim is not incorrect; if you see a U of C doctor on the hospital campus, it doesn't matter if it is in the office building and not in the hospital, it will bill as a hospital visit.

Huh??? And they are billing from the children's hospital, not even the adult hospital???

And the price difference to me? A $250 hospital visit instead of a $30 specialist office visit. According to the billing rep, this will happen every time I have to visit my surgeon.

How can they do this?

 

[Larra]

Hopefullly @DianaCox , or maybe another patient of Dr. Prachand, will have a good answer for this one. In the meantime, I would suggest getting a copy of both your insurance coverage and also of the billing dept. policies. I would also very strongly recommend documenting every phone call with date, time, name and job title of the person you speak with, their phone number, and a summary of the conversation. But bottom line, you need to get ahold of these policies in writing. And don't trust anyone else to get the policies right, even if they work there, or to tell you there is nothing that can be corrected or appealed.

 

[DianaCox]

Ask to speak to the hospital's corporate legal department, and mention words like "insurance fraud." See if that gets any reaction.
And also speak to your insurance company again, and report the claim as "potentially" fraudulent, as you were (1) not admitted, and (2) never in the Children's Hospital.

 

[brooklyngirl]

Wow, that's a bunch of bullshit! I'd follow the advice ^^^