Question
My wife had a total hysterectomy recently at an in-network hospital (not elective - she almost died from massive hemorrhaging). The hospital's bill was $75,000, which was at first denied, the hospital and my wife's doctor submitted additional information, and only $12,000 was paid, leaving the balance unpaid. Will the unpaid balance become my responsibility? Should I appeal with the insurance company (a third-party administrator for my County employer's self-insured plan)? Or will the unpaid balance be written off by the hospital as a "contractual adjustment"? If I appeal, my window to do that is very short, as I was waiting to see what the insurance administrator would pay. If they don't pay the balance after appeal, do I have a reasonable legal basis to sue them for bad faith? If I do that, it would sort of be like suing my employer, since our plan is self-insured, and the third-party administrator is the Plan's (i.e., employer's) agent. Doesn't sound like a great idea, but becoming liable for over $60,000 of unpaid bills doesn't sound too good either. Your advice will be GREATLY appreciated! Thank you!
Answer
Hi Craig!
You need to make certain that your in network hospital holds you liable for the balance. Usually when you stay in an in network hospital most of the balance is considered a contractual write off and you are not liable for most of it.
Call your insurance carrier and ask them directly what they are responsible for and what you are responsible for. You can appeal only if they denied a portion.
Usually bills are very high but the payments are usually much lower.
Good Luck!
Tricia
