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).

[lealea1005]

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.

The patient/consumer has the relationship with their insurance company and, ultimately, the responsibility to know which Physician/facility is on plan. The Physician group has a contract with the hospital to provide services. Unless, they are employees of the hospital, they cannot be forced to negotiate or contract with every insurance company.

IMHO, hospitals should be willing to bite the bullet and employ ER Physicians so situations like OP's don't happen. Bottom line: it's much cheaper for the hospital to contract with Physician groups.

[Scott67]

Yes, I am aware of the insurance companies putting the requirement on the insured. I consider it bad faith on their part for negotiating contracts with hospitals that make it impossible for the insured to comply with this requirement. I'm just giving the OP some rationale that he may want to try in negotiating himself out of the problem. The easy legal answer is that he owes the money. That isn't a very good financial answer.

I haven't found any case law on this. I personally believe it would be an area for an enterprising attorney to pursue a class action suit. It is one thing to hold patients to this requirement when they select a physician to treat them; it is a totally different thing when the physician enters the room while they are unconscious. Just my opinion.

[tmiller35]

Freedom of contract is a noble sounding concept but, in my opinion, does not work when a pre-op patient who has just briefly met her surgeon for a moment before surgery and then is put under,awakens post-op and finds a nurse attending to her while she is still feeling the effects of anesthesia. What should have been done? Should she have demanded to know who he was and if he was in-network when she had never seen him before the surgery? Any judge (magistrate or whatever) hearing this matter worth anything will look at the facts and apply principals of equity to whatever contract might have been agreed to between my wife and this individual provider (if any) and then decide if the doctor who hired him or my wife, who did not hire him. should be liable for payment of his services. The doctor was paid by our carrier "Vita Health" and could cover this person from what "Vita" paid him. That seems fair and reasonable to us. After all, he hired him, We did not. Our insurance is not just any private carrier. They contract directly with Palm beach County and the municipal hospitals like the one we used. This health plan is only available to County residents who are treated at County hospitals. I believe this may strenghten our case, but who knows. When it comes to medical debtors common law contract principals and the Uniform Commercial Code seem to be almost moot!

[lealea1005]

Freedom of contract is a noble sounding concept but, in my opinion, does not work when a pre-op patient who has just briefly met her surgeon for a moment before surgery and then is put under,awakens post-op and finds a nurse attending to her while she is still feeling the effects of anesthesia. What should have been done? Should she have demanded to know who he was and if he was in-network when she had never seen him before the surgery? Any judge (magistrate or whatever) hearing this matter worth anything will look at the facts and apply principals of equity to whatever contract might have been agreed to between my wife and this individual provider (if any) and then decide if the doctor who hired him or my wife, who did not hire him. should be liable for payment of his services. The doctor was paid by our carrier "Vita Health" and could cover this person from what "Vita" paid him. That seems fair and reasonable to us. After all, he hired him, We did not. Our insurance is not just any private carrier. They contract directly with Palm beach County and the municipal hospitals like the one we used. This health plan is only available to County residents who are treated at County hospitals. I believe this may strenghten our case, but who knows. When it comes to medical debtors common law contract principals and the Uniform Commercial Code seem to be almost moot!

As I said...I agree that it's ridiculous and hospitals should be required to employ their ER Physicians, rather than use them as independent contractors. I was just merely stating that hospitals cannot require independent contractors to participate in EVERY insurance plan out there.

I also agree that your Surgeon should , at the very least, have informed you he requires the services of a private duty nurse or aid post-op, and that nurse/aid's services may not be covered by your individual insurance plan...regardless of their network pariticpation.

So...in trying to help you....Do you know if the nurse/aids services were originally submitted as part of your Surgeon's claim? If so, does your explanation of benefits list the CPT (procedure code) submitted for the nurse/aid's service?