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A Perfect Example of Why You Should Never Take a NJ Medical Bill at Face Value

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I have written here on this site about negotiating with medical providers in New Jersey regarding the amount of the bill for their services. Notice I am talking about the negotiation of the amount, not the payment terms. This is because, although I believe medical professionals should be paid for their services, they should not necessarily be paid the amount set forth in their bill.

A Cautionary Tale

I recently came across a great example of what I mean by this. A client of mine in Washington Township, New Jersey, had fallen and broken her arm. After x-rays were taken that determined that she needed surgery to set the bones, she was admitted to the hospital.

She was there for three days, underwent the surgery, and was released. Fortunately she had insurance, and the hospital was "in network," so her portion of the bill was not expected to be that high.

Then Insurance Problems

Then the problems came in. The insurance company denied coverage for two of the three days in the hospital, first because they claimed they did not have enough information from the hospital to process the claim, and then because they had decided those two days were "not medically necessary."

The decision was appealed by the hospital, and the appeal was denied. Following this denial, the hospital sent my client a bill for $37,217! No itemization, breakdown, or statement of what the bill was for; just the amount and a demand that it be paid in 30 days!

If You Don't Like the Bill, Reject It!

I wrote to the hospital rejecting the bill on behalf of my client due to the lack of itemization of services, verification that the amount billed was what the insurance company would have paid, or proof that the bill did not encompass the one day that the insurance company had paid for.

Fortunately, at about the time that the hospital received my letter, the insurance company had changed its mind and paid for all three days. I was told by the hospital that my client now only owed copays and deductibles totaling $2,055.26. Quite a difference!

But the real story is in the final Explanation of Medical Benefits (EOMB) from the insurance carrier. It showed that a bill had been submitted for $37,217, that $21,626.03 was declared "ineligible," and that the approved bill for the services was actually $15,590.97. What can we learn from this?

What Can Be Learned from This? Negotiate!

We can learn several things from this, especially that

  • the hospital initially billed my client for way more than they would have accepted from the insurance company
  • the amount included the charges for a day in the hospital that the insurance company had already agreed to pay for, and
  • my client was actually being penalized for her insurance carrier denying the claim!

In light of all this, if you get a bill from a medical provider, you should be asking yourself questions like:

  • If an insurance company would not pay the bill as presented by the medical provider, why should I?
  • If the medical provider would accept less from an insurance company (in this case 58% less), why should I pay more?
  • If the insurance company believes that $15,590.97 is a reasonable price for the services, why should I pay $37,217?

Is This Happening to You?

If you live in the Gloucester County, New Jersey, have no health insurance, and are being pursued by medical providers for bills in excess of $15,000 to $20,000, call my office at 856-432-4113 or contact me through this site to schedule an appointment in my Woodbury office to come in and discuss representation. I may well be able to get your bills reduced to a manageable amount.

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