Billed the difference between Hospital final Charges for ER visit and the Insurance Co. Max payable cap.

[CLBEC]

We have an Aetna PPO.  We visited the ER.  On the bill states the final amount of charges from the hospital is $418.  Then there is an "Aetna Billed Charge" for $560.  After checking with Aetna they told us that their negotiated rate or cap that the hospital can charge for an ER visit is $979.  I told them that I understood that was the max the hospital could charge in the event we went OVER $979, but since our final billed charges only came to $418, why were we being charged more than that amount.  Aetna said that this was "their way of keeping the hospitals happy".  That "no hospital would ever contract with them if they lost money on the bigger claims through Aetna's negotiated fees, and this was their way of making up the difference".  I exclaimed that "We would have paid LESS money for the ER visit if we had not used our insurance??"  The Aetna representative said "yes" and suggested we "Don't go through our insurance company for this"

This seems ludicrous!  Are they allowed to do this???

[Amir Mostafaie]

Dear CLBEC,

So your statement “Aetna said that this was "their way of keeping the hospitals happy".  That "no hospital would ever contract with them if they lost money on the bigger claims through Aetna's negotiated fees, and this was their way of making up the difference" translates to this; Aetna has a negotiated rate of $979.00 for the services you received through the emergency room. Most of the times negotiated rates save consumers money, but once in a while they may not work in your favor.
I recommend communicating your concern to the billing dept. of the hospital & ask them for a reasonable settlement.

Sincerely,

Amir Mostafaie.

[CLBEC]

I have spoken with the Hospital and they are happy to drop the extra amount.  The representative at Aetna was so bold as to tell the hospital they can charge me whatever they want.  But is advising" them that it's in the hospital's and patient's best interests if they charge me the full $979.00 and if they dont charge me the full amount that it's insurance fraud.  I've told the insurance company that I"m happy to report back to them the corrected amount so they can apply the correct amount to my deductible.  But they say "If the hospital wants to HONOR their contract they have to charge me an extra $560 for services I didn't receive.

I also found out from the hospital that if when we checked in we told them I did not have insurance and went along as a cash paying customer, I would have only been charged $175 for all the services I received, not the $418 they charged me because I'm with Aetna.  

The insurance company told me that they cant cancel or void the claim, but that it's within my rights to decide if I want this to go through my insurance or not.  They tell me I have to have the hospital retract the claim.  The lady in hospital billing says she's never heard of this.  

Do I have the right to demand the hospital retract the claim and only charge me the $175 that they would have charged me if I were a cash paying customer?

[Amir Mostafaie]

Dear CLBEC,

You can try asking the hospital to retract the claim but I believe the $175 charge is for individuals without insurance coverage & would not apply to you. It is best to be consistent & stick to what the hospital initially charged to ($418). You have to be firm (and polite at the same time) with your position & ask Aetna to do the “right” thing for their member!
When appealing your case follow these directions;
- Always look for senior, experienced, informative & compassionate representatives who would take the time to find remedy to your problem.
- Maintain a professional demeanor & attitude and do not take things personally.
- Take notes including representatives’ names, phone numbers & information they give you.  

Sincerely,

Amir Mostafaie