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Treatment Facility Negotiated Payment Rate, Billing for Remainder (Deductible)

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  • 08-04-2011, 03:32 PM
    TeeJay
    Treatment Facility Negotiated Payment Rate, Billing for Remainder (Deductible)
    My question involves collection proceedings in the State of: Massachusetts

    I was working for a company in another state, when I needed treatment at a facility that my insurance had did not have any in-network providers for.

    I arrived at the facility in MA, where my family lives, for a consult. They explained based on my condition that I had to go into the facility immediately. The facility said that they would take care of my insurance. I was informed by the facility that the insurance company approved, and would continue to seek approval. Each week they told me my insurance agreed. What I did not know was that they agreement they reached was to cover only 40%, with 60% to be covered by me. I had the highest cost plan that was offered by my company. They billed me for the remainder which was $25,000. The insurance company told me that I could not appeal this.

    The facility called my parents to demand payment in full last year. They also called me once or twice since, and have now sent this to a collections agent.

    It seems deceptive to me that they didn't tell me that they had negotiated a rate I would never have accepted. For better or worse, I would have said I could not ever stay there. I feel strongly they led me to believe that insurance was covering my stay, they even commented how surprised they were about how "good" my insurance was being. Other people were frequently turned out from this facility when they realized that they were unable to pay.

    I have no property except for a car. I do not know what my rights are or what they can do to me. I am reluctant to agree to a payment plan before I know for certain that I should be responsible for the entire amount. Do I need a lawyer?

    Thank you for your guidance.
  • 08-05-2011, 05:01 AM
    lealea1005
    Re: Treatment Facility Negotiated Payment Rate, Billing for Remainder (Deductible)
    Quote:

    They explained based on my condition that I had to go into the facility immediately. The facility said that they would take care of my insurance. I was informed by the facility that the insurance company approved, and would continue to seek approval. Each week they told me my insurance agreed. What I did not know was that they agreement they reached was to cover only 40%, with 60% to be covered by me.
    If a facility is not in network/contracted with your insurance company, they have no obligation to accept what your insurance company pays them as payment in full.

    Quote:

    I had the highest cost plan that was offered by my company.
    Which is probably why you had out of network benefits available to you.

    Quote:

    It seems deceptive to me that they didn't tell me that they had negotiated a rate I would never have accepted. For better or worse, I would have said I could not ever stay there. I feel strongly they led me to believe that insurance was covering my stay, they even commented how surprised they were about how "good" my insurance was being.
    They weren't being deceptive at all. Your insurance company sent them their (your insurance company's) negotiatted rate payment for in network/contracted Physicians, which was 40% of the facility's ( who are not in network or contracted) fee. Honestly, youwere lucky you had some sort of out of network benefits with your insurance company. Many people do not have that option.

    Quote:

    I am reluctant to agree to a payment plan before I know for certain that I should be responsible for the entire amount.
    You are responsible to pay the remaining amount. I suggest you call and work out some sort of payment plan. Good luck.
  • 08-05-2011, 09:33 AM
    TeeJay
    Re: Treatment Facility Negotiated Payment Rate, Billing for Remainder (Deductible)
    Thank you for responding. It is interesting to hear a different perspective from what I have heard from peers.

    I suppose lucky a relative term. Am I am lucky that I actually got treatment and did not die? Sure.
    Am I lucky that I did not get charged the whole amount? I guess, but isn't that what I worked for? I have less of a problem with my insurance who offered me a good chunk to help, and didn't deny the claims. Thank goodness for those people.

    Please don't think me ungrateful, but I don't feel very fortunate. I feel taken advantage of by the treatment facility, when I was in a terribly vulnerable situation.

    Quote:

    They weren't being deceptive at all . Your insurance company sent them their (your insurance company's) negotiated rate payment for in network/contracted Physicians, which was 40% of the facility's ( who are not in network or contracted) fee.
    I see your opinion that they weren't being deceptive. However, I would like to point out that they actually specifically negotiated this fee as in they had a talk about my case, and decided to only tell me every week that my insurance was going to "cover it." The specifically made a special agreement for payment with my insurance that was not for the full amount, and told me that insurance was covering it. I don't think I would be alone in saying that this seems misleading.

    As a point of interest, I was present when many patients were taken aside (at first) to discuss, and then later "tossed" from this facility, when it was found they couldn't pay in full, despite their failing health. I wonder what made me different. Why tell me that insurance would cover it, when they weren't? Why not take me aside to discuss? The fact that my discussions with them about insurance never addressed any additional repayment, contributed to my belief that insurance was indeed covering it and they were telling me the full truth.

    Also, although you advised that I set up a payment plan, but this is a little different than what I asked about. I asked if you think I should contact a lawyer, if you knew what my rights are, and what they could do to me in the event I cannot pay.

    I do appreciate that you wrote back, I really do.
    I am trying to deal with this scary situation the best I can. I am sure that you can understand that when people write here they are desperate, and are re-living whatever bad thing sent them to seek care in the first place. While I appreciate your directness, it is often easier to accept advice from someone who appears to understand what you are going through not just as another case, but another human.

    Nevertheless, I appreciate your post, and if you had any other thoughts I would be grateful to hear them.
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