Steps to Take When an Unexpected Medical Bill Comes in the Mail

An unexpected bill arrives from a medical laboratory months after you
underwent a battery of tests for a health condition. The charges are
surprising because you paid a co-payment at the time of the exam, and
you expected your health plan to cover the rest.

But your insurer says some of the tests weren’t authorized, and if you don’t pay up, you’ll be sent to collections.

You’re
certain the bill is a mistake, but how do you get it fixed? Do you
complain to your health plan? Do you call your doctor? Do you contact a
lawyer?

Figuring out how to lodge a complaint in our highly fractured health care system can be a bewildering ordeal.

For
starters, you have to determine who is responsible for the situation.
It might be a hospital or perhaps a doctor or the doctor’s medical
group or maybe an insurer.

And what if you decide to take your complaint to the next level?

More
than 15 local, state and federal agencies regulate nearly every aspect
of the health care system, but finding the one that deals with your
particular problem can be a tall order.

"It’s
rather complicated, and there’s not one answer for everyone," said Ed
Mendoza, deputy director of the California Office of the Patient
Advocate.

California regulators in 2007 received
14,000 formal complaints about insurers, hospitals and doctors. In San
Diego County, 213 complaints were lodged against the area’s 20
hospitals, up 18 percent from the previous year. Local figures weren’t
available for complaints against insurers and doctors.

Count Albert Elliot, 83, among the ranks of the confused.

The
retired contractor from San Diego’s South Bay area was furious when he
received an $817 bill from Sharp Chula Vista Medical Center for an
overnight stay by his wife, Verna, more than a year earlier.

Verna,
who was 81 at the time, had been on a trip to the Grand Canyon when she
started suffering symptoms of altitude sickness. She quickly returned
to Chula Vista and headed straight to Sharp’s emergency room, where she
was checked by doctors and admitted overnight.

When she left the hospital the next day, Albert paid nearly $200 in co-payments for the stay.

The hospital clerk "didn’t indicate at all that I owed more money," Albert said.

The
bill that arrived 14 months later told a different story. It listed
$21,640 in total charges for Vera’s hospital stay. A downward
adjustment of $20,823 left a balance of $817.

Unfortunately,
Verna had died three months earlier of heart failure unrelated to the
Grand Canyon incident. That made it difficult for Albert to verify
whether the charges on the bill were accurate.

He
sent a letter to Sharp in response, noting his wife’s death and
suggesting that the bill be redirected to the couple’s health plan.

A
few weeks later, a letter from the hospital arrived in the mail
indicating that the account would be turned over to a collection agency
unless it was paid.

Sharp Chula Vista spokeswoman
Christina Orlovsky declined to comment on Elliot’s situation, but she
noted that billings aren’t unusual, considering the complex
relationships the exist among players in the health care system.

"We
always understand the frustration of the billing process," she said.
"We are always willing to help explain (the patient’s) financial
responsibility as long as they call and alert us of the situation."

Elliot said he shouldn’t have received the bill in the first place.

"I’m on Social Security," he said. "I have a small savings, but I’m not going to give it to them."

He didn’t know where to turn. "How would I know who to call?" he said.

Here is a potential course of action:

*
For starters, he should dial up his health plan and ask why the bill
wasn’t paid in full. It could be a paperwork glitch or a simple
misunderstanding between the insurer and hospital.

"The
idea is to get the complaint resolved at the lowest level as quickly as
possible," said Mendoza of the state’s Patient Advocate office.

*
If that doesn’t fix things, then he should file a formal complaint with
the insurer. State law requires patients to take this step before
seeking help from regulators.

* If after 30 days
the health plan hasn’t resolved the complaint satisfactorily, then he
can file a grievance with the state Department of Managed Health Care
by calling the state’s HMO Help Center toll-free at (888) 466-2219.

The
center receives about 3,500 calls each month concerning health plan
complaints, Mendoza said. "In some cases, we get on the phone with the
health plan and the enrollee together, and resolve the problem."

Preferred
provider organizations are regulated separately by the Department of
Insurance, which means that people who receive health care services
through PPO’s should call the department’s consumer hotline at (800)
927-4357 for help.

Medicare beneficiaries can call
the Health Insurance Counseling and Advocacy Program (HICAP) at (800)
434-0222 or Lumetra at (800) 841-1602. HICAP is administered by the
California Department of Aging and offers free services. Lumetra is
contracted by the federal government to help resolve Medicare disputes.

In
most cases, insurers and regulators are required to respond to
complaints within 30 days. In emergency situations, patients can
request expedited consideration.

Regulators are
quick to note that they aren’t able to help consumers who don’t make
their problems known. "It’s very important that we hear from people,"
said Laura Dooley Beile, a manager in the division of the Department of
Managed Health Care that oversees the HMO Help Center.

Unusually large numbers of complaints often raise red flags with regulators and trigger investigations.

As
a last resort, consumers can seek help from a lawyer if regulators
aren’t able to resolve their problem, but the cost of litigation often
outweighs the amount of the disputed bill.

Problems
with a physician should be directed to the Medical Board of California,
which is responsible for licensing and investigating doctors. The
board’s toll-free complaint line is (800) 633-2322.

Complaints
against other health care professionals who are licensed by other
organizations should be directed to the appropriate agency, such as the
Board of Chiropractic Examiners for chiropractors or Board of Optometry
for optometrists.

Complaints against hospitals
should be directed to the state Department of Public Health — (800)
824-0613 is the number to call if you are a patient in a hospital north
of Interstate 8 in San Diego County and (866) 706-0759 is the number
for hospitals south of the highway.

More Calling Options:

Other resources that can be helpful when you have a health-care complaint:

* Consumer Watchdog, formerly The Foundation for Taxpayer and Consumer Rights, offers "The California Patient’s Guide" online at: www.calpatientguide.org. Contact at: (310) 392-0522.

* The Legal Aid Society of San Diego operates the Consumer Center for
Health, Education and Advocacy, a program that helps local consumers
get the health care they need. Contact the program at: (877) 734-3258.

* The Office of the Patient Advocate offers advice on addressing problems
with health plans at: www.opa.ca.gov/healthcare/problems/index.aspx. Call the state’s HMO Help Center at (888) 466-2219.

* The Health Rights Hotline offers tips on dealing with insurance complaints at: www.hrh.org/cag/agwhat.html