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4gotmylife · May 12, 2006, 10:26 PM

I live in TN. I was hospitalized for depression last year 2 times. My insurance approved my first hospitalization. When I was readmitted a few weeks later, my insurance company again approved my admission which was felt to be semi-urgent. To make a long story short, my insurance company, BC/BS, has now denied my 2nd hospitalization after precertifying it and the hospital has billed me $20K for the 2nd admission. I do not deny that I owe my co-pay and out of pocket for the first hospitalization, but am I liable if both I and the hospital were deceived into believing my 2nd hospitalization was covered, only to have BC/BS deny the claim some 3-4 months following my discharge? I would have checked out of the hospital had I know I no longer had mental health coverage. There was a maximum amount of days I had exceeded, which I was unaware of, but BC/BS knew or overlooked. Either way, I feel they dropped the ball, and now I owe a $20K plus the other bill, which I realize I am liable for, which is about $7K. I still have not returned to work full time and my income less than half of what it was in 2004, as I was off work, on short-term disability for about 5 months in 2005. HELP!! :eek:

ScottGem · May 13, 2006, 06:00 AM

I would consult a lawyer. But if your insurance precertified the stay and you were admitted only on the strength of that precertification then I would say you are in the clear. However, it may cost you to prove it.

One idea that comes to mind is consulting with the hospital's lawyers. They may feel suing the insurance company gives them a better chance of recovering the costs.

J_9 · May 13, 2006, 05:40 PM

I agree with ScottGem on this one. Contact the hospital's legal department. If it is documented in your chart that you had a pre-cert, then you should be clear. Sometimes with a hospital like Charter Lakeside that is in my community, they will work with the patient to get to the bottom of it.

Fr_Chuck · May 13, 2006, 07:20 PM

I will agree to a point.

First you have a legal contract with the hosptial. This is between you and them, normally it will say that the bill is your responsibility, if you have insurance they will accept it and bill it but if they don't pay, you are responsible.

So most likely between you and the hospital, the hospital can hold you responsible for the payment.

Now because they gave you information that it would be covered, you may have a case against them. In this case, of course according to the rules you will need to file an appeal to their appeal division.

Often many cases are oked once they go to appeal, I have many many health claims each year and I get about 3 or 4 denied on the first pass, but get all of them oked on appeal.

So in the end, the hospital will hold you responsible an bill you, You will have to deal with the insurance company either by appeal or by law suit.

You need to work out an arrangement with the hosopial to keep them from sending this to collections and ruining your credit while you deal with the insurance company.

Anyway this is how I view it, from common practices and common forms used by hospitals. Only you will know what you signed at the hospital.