scam or not?

[u/ConsequenceOver9269]

last month i went to fl for a week and went to the ER for a uti, as that is the only place to take my insurance. i received a bill from the ER already for $50 after insurance covered 2.5k for lab, ER and pharmacy. today i received a bill from physicanbillpay.com for $1,261 and a bill from east coast pathology of florida for $40 from my UAC. i was wondering if these 2 bills are scams. they came in about 2 weeks after my ER bill.

[u/Sloppysteaksslick]

No. The hospital split billed. It's legit, albeit annoying for patients.

Almost all hospitals now split bill, meaning facility charges and physician charges are sent separately, sometimes from different billing entities.

The pathology bill sounds high, though as does the physician bill. You were probably seen by an out of network provider and the UTI test was probably sent out of network as well. If that's the case, you can argue that. Although, surprise billing laws are really made for emergency situations.

You need to make sure you go to an urgent care next time you're in a situation like that.

[u/YogurtclosetOpen3567 → u/Sloppysteaksslick]

Wait are you saying the hospital contracts seperately or the hospital send you different bills under the same network

[u/Sloppysteaksslick → u/YogurtclosetOpen3567]

So it can be both. Some hospitals employ all their providers themselves under the facility org. Some hospitals employ some of their providers under the org. but also supplement their providers with contracted providers not technically under their main org. Some hospitals don't employ any providers under their own main org and only contract.

Some hospitals bill all their services under one umbrella (facility, physician, lab/pathology). Some hospitals bill only their own facility fees and then contract out physician fees, etc . to a billing service which bill the patients separately from the hospital .Some might do this but vice versa but that would be rare.

Sometimes if the physician billing is separate from the hospital, and the provider is just a contract provider, there might even be another third party billing service.

[u/YogurtclosetOpen3567 → u/Sloppysteaksslick]

So how would charity care work under each of the theee scenarios you speak of?

[u/Sloppysteaksslick → u/YogurtclosetOpen3567]

That depends. For example, I currently work for a physician side billing service and we do not provide any charity, that's all done through the hospital/facility side. So patients might get charity through the hospital and not realize that it only counts towards the facility fees. We do however, work with them and perform a "Charity" adjustment of 20% for the physician fees if they were approved for charity through the hospital.

[u/YogurtclosetOpen3567 → u/Sloppysteaksslick]

Wait so if they can’t afford and then you don’t have to provide charity care then do you take them to court and garnish their wages or foreclose on their homes?

[u/Sloppysteaksslick → u/YogurtclosetOpen3567]

No. We do not. There are facilities who do. We have a committee that meets monthly to decide what to write off for patients in that scenario.

[u/YogurtclosetOpen3567 → u/Sloppysteaksslick]

Oh so you do provide charity care effectively? See that’s really interesting, my understanding is that the hospitals tend to be much more punitive but apparently physician groups more recently have been getting with debt collectors to sue?

[u/Sloppysteaksslick → u/YogurtclosetOpen3567]

We only started recently reviewing all charity cases because of some new laws and regulations in my state. I wish we could just write everything off for everyone struggling.

It is considering charity write offs but it's not a taxing district charity type plan like the hospital provides.

The physician groups are getting paid less and less from insurance and yes, they've become the "bad guys".

[u/YogurtclosetOpen3567 → u/Sloppysteaksslick]

Oh I see so the state is requiring now that you do NOT provide charity care and so you only sue a certain amount of patients as opposed to hospital which is most?

[u/ConsequenceOver9269 → u/Sloppysteaksslick]

the urgent care is the one who told me to go to the ER

[u/Sloppysteaksslick → u/ConsequenceOver9269]

That's unfortunate. I would have stayed at the urgent care and paid out of pocket. It's very annoying for patients. I'm sorry that you incurred those charges.

[u/ConsequenceOver9269 → u/Sloppysteaksslick]

i js wanted to make sure is physicianbillpay is legit, the website is very sketchy and even the bill i received looks sketchy. i googled them and found nothing good about them. i’ll call the hospital tomorrow and my insurance about it.

[u/Sloppysteaksslick → u/ConsequenceOver9269]

I don't think I've heard of that one 🤷. Call the hospital and check to see who they use for their physician billing.

[u/Zetavu → u/ConsequenceOver9269]

Always check your insurance to make sure they submitted it there. If they are out of network it should still work through in network insurance if you were at an in network hospital. I've seen some issue and typically insurance forces them to take in network pay which is lower. They will obviously try to get you to pay out of network rates if they can.

[u/EmZee2022 → u/Sloppysteaksslick]

Actually, No Surprises ought to cover this. The OP went to an in-network hospital and secondary practitioners should be covered under NSA.

Whether the 1200 dollar bill from the physician is a valid amount or not, it's hard to tell. Has insurance covered any of it yet? If not, wait until they process it, and pay what insurance says you owe. I don't know how your plan works with physician coverage for emergency services, whether you've met your deductible yet, and so on.

The doctor who saw you there is likely a contractor, which is why you got a separate bill.

The pathology is odd: since you say your initial bill included labs, I would not have expected them to need to send out anything to a path lab. But I don't know everything :-)

The fun of our healthcare system is that for any hospital encounter, you will get a MINIMUM of 2 separate bills, one for the facility and one for the doctor. For my colonoscopies, I get a facility bill, a doctor bill, an anesthesiology bill, and a pathology bill. You can also run into bills for imaging services, and possibly others that don't come quickly to mind. Surgery I had recently incurred bills from the doctor, the hospital, the pathologist, and the anesthesiologist (2 of them, for some reason).

I had an ER visit last year for diarrhea that lasted a week, was not improving, and left me clinically dehydrated. That incurred a huge bill (8800) from the hospital, a smaller one (800) from the radiology practice, and one for about 1600 from the doctor (I assume; the EOB isn't terribly detailed). Obviously the negotiated rates were a lot less.

[u/Sloppysteaksslick → u/EmZee2022]

I didn't say it wouldn't cover it. I just said the rule was created truly for emergency situations.

[u/EmZee2022 → u/Sloppysteaksslick]

For emergencies, but also the situation where you are receiving services at an in-network facility, but some of the staff (anesthesiologists etc.) are contractors and not in-network. You have no real control over such providers.

Friends of mine got a 4,000 dollar bill for anesthesiology for a colonoscopy. Having had a few of those myself, 4K is about triple the "rack rate" my place bills for that, and about 10 times what the provider actually receives. In theory, the practice could have demanded the full 4K (they actually wrote of the bulk of it) as this was long before NSA. With NSA, the anesthesiologist could not collect more than the 400 dollars or whatever that they'd have paid an in-network provider.

[u/Sloppysteaksslick → u/EmZee2022]

Believe me. I work in the field that created the law and worked with those who drafted it. It was created initially to protect patients from "surprise" out of network bills in emergency situations. It has since, luckily expanded within certain healthcare systems due to the gray area of what constitutes an emergency.

I'm happy that your friend got their bill taken care of appropriately.

[u/EmZee2022 → u/Sloppysteaksslick]

Good to know!!

From what I see in the forums, the ambulance industry managed to lobby enough to get excluded from the bill :-(

[u/Sloppysteaksslick → u/EmZee2022]

Yes. They truly suck! Most of the ambulances in the U.S are privately owned and operated with just a contract between them and the hospitals. It's a big scam.

[u/EmZee2022 → u/Sloppysteaksslick]

I'm curious as to how ambulance billing works if it's a municipally-provided service. If I dial 911 here, I get someone showing up in a vehicle branded with the county's fire department logo. Luckily we've never needed to test this out.

[u/dadayaka]

They are legit, just separate billing entities. Facility, Provider (doctor), and the pathology lab.

The 50$ you paid is likely your copay for an ER visit. You may still have a deductible or co insurance, though. Does anything on the 1261 bill say if its been processed through your insurance? If not, there should be a phone number on the bill you can call and ask them to submit to your insurance.

You're likely responsible for the 40$ bill. That sounds about right for a path lab copay/co insurance.

If you have an online portal for your insurance you can check there for the EOBs that will tell you what your portion is in detail. If the EOB says its been paid in full and you have a 0$ balance then this is considered balanced billing which cant be done under the NSBA. Call the billing office number and explain your insurance has paid in full and they shouldn't bill you. If they refuse to stop you can talk to your insurance and they should have a department that will help.

[u/ConsequenceOver9269 → u/dadayaka]

the $50 was my balanced after adjustments, not copay. it’s ac $50.64 ik the ER one is legit. the physicanbillpay bill didn’t even mention my insurance adjustments.

the pathology place is billing me for urinalysis w scope, urine culture, pregnancy test, gram negative microbe susceptibility; all of which was already in my ER lab bill. i’m confused why i have to pay for these services twice

[u/Open_Trouble_6005 → u/ConsequenceOver9269]

Did you review the explanation of benefits from your insurance company for each of these providers? The insurance should have the same information as you and your balances should match up with what you are being asked to pay. I do wonder if that physician bill has been processed by insurance. Go online or call your plan and review this with them.

[u/dadayaka → u/ConsequenceOver9269]

I would suggest calling the billing office number on the bills. The physician one sounds like it hasn't been processed through the insurance which does happen a lot. Just give them your info and they'll get it sorted. You may still have a coinsurance/deductible (thats the balance after the adjustment) but it wont be the whole bill.

The pathology one could be a physician bill as well, just a separate doctor who read and interpreted the tests. The reason it seems to be billed twice is because there is a technical component and a professional component. The TC is billed on the facility bill (the ER bill you've gotten already). The PC part is billed separate just like the provider you saw.

So the same thing applies. Call the billing office number on that bill and provide your insurance information. They'll bill it to your insurance and you may or may not have a balance on that.