In Hospital Post Op Nurse Works in Hospital but Not Part of Our Major Medical Plan

[tmiller35]

My question involves collection proceedings in the State of: Florida

My wife had a surgical procedure done as an outpatient recently. Post op a nurse/aid attended to her for about an hour or so before she was released. A few months later we received a bill for his services and he claimed our insurance carrier (which covered the entire procedure except his services) kicked his claim back. He never told her he was not affiliated with the hospital (a freelencer?) and, in any case, she was in no condition mentally right after surgery to accept or reject the services of what we now know was a private nurse that we would be obligated to pay out-of-pocket. He is looking to collect a fee for what we feel is an agreement never made. We believed, at the time, that he was on staff at the hospital. Please advise.

[Mr. Knowitall]

How did this nurse's aid enter the picture - who hired him, and how did he gain access to post-op? Is he claiming that your wife consented to treatment by him, separate and apart from her general agreement to be treated by the hospital, while she was coming out of anesthesia? Have you asked the hospital about this?

[tmiller35]

They are claiming the surgeon hired him. Our insurance is private but is subsidized by Palm Beach County. We received a letter before choosing Del Ray Medical Center in Del Ray Beach, FL that the hospital was on our "Vita Health" plan. Palm Beach County was representing to us that the hospital was on our plan, not just a private insurance carrier. Were we then obligated to ascertain if each individual working at the hospital who attended to my wife was separately part of the plan? This seems very unreasonable especially when the entire procedure was on an outpatient basis, in by 7 AM, out before noon and only this one person claims now to be not on our plan.

Thank you for your assistance. We are most grateful as we are facing unprecedented hard economic times and the last thing we need in 2009 is another bill to pay!

Kindest regards,
Thomas J. Miller

[Scott67]

Get ready for a battle. I had a similar case with one of my dependents in a California hospital a number of years ago. This was an ER visit to an in-network hospital in which the attending ER physician was not on the plan. The three parties - the hospital, the insurance company and the doctor's bill collector - all maintained that it wasn't their problem, each for the reasons you can surmise.

Over a period of a year, while receiving regular bills from the physician, I wrote a number of letters to each, ending with a letter addressed to all three telling them the responsibility that I felt each had in the problem, that I had done all I could be expected to do, and they should resolve it among them. I received nothing from any of them since then (about 10 years). Not a good clean legal solution, but it appears resolved, I'm guessing with the physician writing off the bill. You might try something similar.

[lealea1005]

I received nothing from any of them since then (about 10 years). Not a good clean legal solution, but it appears resolved, I'm guessing with the physician writing off the bill.

What most likely happened is that the Physician agreed to accept what the insurance company would have paid if s/he was a contracted provider.

Physicians deserve to be paid for their services. Hospitals cannot dictate which insurance company contract participation from their ER Physician groups, or other admitting Physicians...unless, of course, the Physicians are employees of the hospital.

Quote by OP:

Were we then obligated to ascertain if each individual working at the hospital who attended to my wife was separately part of the plan? This seems very unreasonable especially when the entire procedure was on an outpatient basis, in by 7 AM, out before noon and only this one person claims now to be not on our plan.

Yes, it is your responsibility to confirm that your surgeon/admitting Physician is contracted with your insurance company. It may seem unreasonable (and I'm not disagreeing with that) but, ultimately, it's your resposnsibility.

Does the aid work for an agency, your surgeon, or is he self employed?

[Scott67]

Physicians deserve to be paid for their services. Hospitals cannot dictate which insurance company contract participation from their ER Physician groups, or other admitting Physicians...unless, of course, the Physicians are employees of the hospital.

Just one comment on this: Yes, physicians should be paid for their services. In all but the most critical situations, the hospital will not treat a patient until insurance information is provided (although for people without insurance they just skip this step). I believe the hospital has all the information it needs to ensure that providers are in the insured's plan. But, the patient has no way to ensure that people treating him/her are in the managed care contract. The reason it doesn't happen more often is that most physicians working in an in-network hospital are in the network. My point is that this is all about the contracts and business relationships between the insurance company, the hospital and the physicians. It should not be the patient's responsibility if their system breaks. (btw, that's the short form of the argument that I had in the letter that seemed to settle my situation).