Joined: 02 May 2007 Posts: 1 Location: Los Angeles
Insurance Company Splitting Bill to Collect More Deductible Posted: 05-02-07 20:37pm
Hi,
We have a question regarding a rather
offensive practice of Blue Shield of
California. I don't know what is 'normal'
and am hoping to get some insight.
Our daughter was born with crash C-section
in 12/20/06, spent 14 days in the NICU,
and was discharged on 01/03/07. The
hospitalization was continuous, and
apparently ran up a bill of about
$200,000. We're on a 2400/4800 PPO/HSA
plan with $5,800 out of pocket maximum,
and we easily met that maximum for 2006.
We were told throughout that since our
daughter was admitted in December 2006,
the entire hospitalization would be one
claim, and would only be applied to our
2006 deductible. We were told this many
times by Blue Shield, and they also paid
100% of discharge medicine on Jan. 03.,
meaning that they at least at that point
agreed that the entire hospitalization
would go on 2006.
We've long since paid our final bill, and
now we're getting a new final bill for
another $1,600, which is apparently for
services in 2007. We called Blue Shield,
and were told that this was because the
hospital was splitting the claim into two
claims, one for 12/20 to 12/31, and one
for 01/01 to 01/03. The lady said that
according to the hospital, we went home on
on the 31st and came back to the hospital
on the 1st, which of course would have
been catastrophic for our daughter. She
said that we were right, if we were in the
hospital continuously, it should be billed
as one claim, and we shouldn't be paying
deductible in 2007 on a largely 2006
hospitalization.
So we called the hospital (Good Samaritan
Hospital in Los Angeles), who said that,
no, they billed the entire thing as one
claim. They called Blue Shield on our
behalf, who said that it was their policy
to split it at years end. I should add
that I had been explicitly told at least 5
times that the entire hospitalization
would go on 2006 deductible, so obviously,
either all their employees don't know what
they're talking about, or someone is
suddenly changing the rules in order to
simply grab more money, figuring that we
cost them $200,000, so we're going to just
bill them some more money so we collect
something, and good luck being up against
us, a big corporation. This is what I
figure is happening.
I called Blue Shield again, this time for
the first time recording the call, and
talking to a lady about this. She sat for
a really, really long time reading her
computer screen, not being very
responsive, and then finally after 10
minutes saying that she had to find out
why it was billed like that, and that she
would call us back. That was 2 days ago.
Now, I'm reading in our contract that they
talk about Calender Years, and there's
really no talk about processing things as
'claims'. So the question is, is what Blue
Shield is doing legal? I know Blue Shield
is in trouble because they've been
arbitrarily cancelling policies of lossy
members (they've been fined millions of
dollars in California), and suddenly
they're not so trustworthy anymore. You
could easily imagine that they do this
when someone has cost them too much money.
I agree, we've cost them a lot of money,
and it would take them 40 years to recoup
it from our premium, but still, this is
the whole purpose of insurance, to spread
the risk. We don't feel it's fair that
they simply slap on another $1,600 by
manipulating the bill into two claims, one
for each year, instead of one.
So the question is,
(1) Since the contract talks about
calender years, haven't we really allowed
them to do this? On the other hand, why
did they then pay 100% of the discharge
medication on the 3rd of January?
Shouldn't I have paid all that from my
deductible? It doesn't make sense.
(2) What is normal?
(3) Should we get in touch with some sort
of ombudsman to file a complaint, or
should we get legal assistance?
I'd really appreciate if anyone could
offer some insights!
