Reasonable charges...what??!

[lelc2002@yahoo]

It seems to me that my insurance company now goes on 'reasonable costs' theory now....for example: My hospital bill for 10 days in NYcity was about 153,000. Aetna paid (initially) 76,000 saying this is the reasonable charge for my hospital stay.... this is unacceptable& so I told my ins. co to negotiate/work this out with the hospital. I am keeping a log/ detailed call info on all my claims esp. this one....this should be worked out between the 2 parties since we cannot fathom what the hospital charges can come to.....Ly anybody else going thru this?????

[LindaRacine]

Hi Ly...

I think this sort of thing only comes into play when one chooses out-of-network providers. For my insurance, when I'm in network, I only pay a flat $250 for each hospitalization.

--Linda

[lnetzer]

It is a really good idea to keep a detailed log of every single call you make regarding your surgery (date, time, who you talked to). I made 17 calls one week between the insurance, doctors' offices, my husband's employer. Before my son's surgery I blindly accepted that the explanation of benefits sheets that came from the insurance were correct. Now I go over everything with a fine tooth comb after all the errors I've found with the insurance not paying what they're supposed to. I have a friend that does this every day as her job, and she said to check if your insurance has a cap on the amount you have to pay as well. Many of them do. Also to fight that customary charges thing because we had that for our anesthesiolgist, and she said that is something you normally don't get to choose so they can't say it's out of network. Just my two cents worth , hope it helps some!

[majose]

Depends on what type of policy you have

Unfortunatley the costs an insurance company pays is dependent on the type of policy you have. You should have a benefits package booklet that Aetna should have sent you - read it over with a fine toothed comb and see where you can get them to pay more. Look particularly for you Maximum out of pocket limit with regards to hospitalization- this is the maximum amount of money you are liable for, after reaching this limit the insurance company in theory is liable for paying 100% of your costs. Aditionally - if the hospital is an in network hospital, they have agreed to set the rates and the hospital has agreed to accept those rates as the rates they will receive from the insurance company.

The insurance companies have limits on several items for hospitalizations such as room - normally they will only pay for a semi private room,

Ask them what data base they are using to determine reasonable and customary charges - is it the Governement's for Medicare/Medicaid (lowest around) or another - ask if they are basing it on the first 2, 3 or 4 digits of the zip code,

It may be a pain in the butt to do (I did it when my son was born), but get a copy of the hospital bill, and call the hospitals in NYC and ask them (document it) what they cahrge for each procedure code listed on your hopital bill - more likely than not, they will be in the ball park of what your hospital charged you - then send that info off to the insurance co.

I could go on about this - if you need further help on this, feel free to email me. I have had to deal too often with insurance companies trying to avoid paying up, as well as hospitals charging more than once for the same procedure, as was the case with my son's circumsision!

MJP