Hospital bill insanity - excuse me Tricare? I might have to "float a check" until payday.

[oldfella1962]

Okay I got my first statement from Tricare concerning my wife's (still ongoing) medical care. True to form, the statement came today, when Tricare is shut down for a three-day weekend. That said, the statement
is well over a dozen pages long, but the "grand total" is on page #1.
I'll round it off for brevity:
AMOUNT BILLED - $ 700,000 DOLLARS. Not a typo, not Zimbabwe dollars - 700,000 Yankee dollars.
TRICARE ALLOWED - ZERO
TRICARE PAID - ZERO
Bear in mind I called Humana/Tricare constantly throughout the medical ordeal asking them "Is this allowed"? "Is that allowed"? They assured me that everything was indeed allowed, or the hospital wouldn't
treat her in the first place. Hospitals get Tricare approval upfront, so they don't get stuck with a bill few patients could ever pay. So my "on topic" question is - has anybody else here ever received a MOAB (Mother of All Bills) from health care providers because Tricare didn't cover a dime of the alleged "pre-approved" medical care? Sidenote how much did my blood pressure spike when I saw that statement? I wish I was hooked up to a cuff to find out.

 

[Milkman]

What is your question?

 

[georgia_home]

check in to the claims appeal process on your policy.

ive had to appeal claims they denied. I’ve been successful… mostly. Most recently er doctor (I asked to make sure in network, they didn’t and doc wasn’t) and necessity of er trip. (Denied, but on appeal, showing them that delaudad???? Was required was sufficient to win. yeah that’s not otc meds)

 

[oldfella1962]

What is your question?

What is your question?

Yes, I guess that would be helpful! My question is this: has anybody here (most likely retired military or they know retired military members) been sent a statement with an astronomically high amount before? Is this a typical occurrence with billing companies/departments? I'm guessing that everything being computerized and/or ran through second/third/fourth party billing companies equates to initial statements are never even close to reality and have never even been reviewed by human eyes working at the actual insurance company (Humana/Tricare in my case) that will be responsible for paying the medical bills.

Sidenote I am seeing the names of hospitals/companies/doctors that I have never even heard of before. I'm guessing outside sub-contracted companies & doctors? It's quite a complex system!

 

[oldfella1962]

check in to the claims appeal process on your policy.

ive had to appeal claims they denied. I’ve been successful… mostly. Most recently er doctor (I asked to make sure in network, they didn’t and doc wasn’t) and necessity of er trip. (Denied, but on appeal, showing them that delaudad???? Was required was sufficient to win. yeah that’s not otc meds)

I did find out - after the fact - that some of the doctors at one of the hospitals were not hospital employees, they were private contractors working AT the hospital, not FOR the hospital. The hospital did not tell me up front - I had to find out via the Humana insurance employee assigned to my wife's case.

I still remember hearing "don't even worry about the insurance & financial details! Just focus on your wife - we have everything covered from our end! We've done this a million times!" on many occasions. I guess I will find out Tuesday how accurate these reassuring statements were.

 

[georgia_home]

on last colonoscopy as the prepped me on the table, before the sleepy time meds, I asked that anyone not covered by my plan leave the room and that I would NOT pay if they were out of network.

they looked unamused. The parts of their faces I could see around the masks. It was serious. Not sure how much legal weight it would have carried. Probably none. But it was said. I didn’t choose anyone in the room specifically, except the doctor and sketch artist

 

[Ruger#3]

I’ve only had one and it may relate your situation, you will have to do some leg work to see. After a preauthorized surgery I received a bill for anesthesia services. Hospitals out source services that may not be included in your hospital bill. The procedure at the hospital and your doc may be preauthorized but that doesn’t guarantee everyone needed in the surgery room is. I now ask if there’s outsourced services that might need a preauthorization involved.

 

[oldfella1962]

I’ve only had one and it may relate your situation, you will have to do some leg work to see. After a preauthorized surgery I received a bill for anesthesia services. Hospitals out source services that may not be included in your hospital bill. The procedure at the hospital and your doc may be preauthorized but that doesn’t guarantee everyone needed in the surgery room is. I now ask if there’s outsourced services that might need a preauthorization involved.

Yes I have been through the "outsourced services" thing before. Interesting how the burden is on the patient - and not the clinic or hospital - to make it clear who & who is not part of the medical staff that your insurance covers. It's like when the grocery store checkout clerk asks you how much something costs when the barcode falls off the item. YOU WORK HERE LADY! I'm just a one-time customer! One actual doctor bill I'm curious about is one of the doctors from the last hospitals in the chain where my wife stayed. He was a "surprise! This doctor is not on Tricare's radar" doctor. I have no idea what he will charge. He came in to see every patient daily - sometimes for 30 seconds, sometimes for three minutes if they had a question or concern. I asked the hospital what he charged, but they said they had no idea - that's his business not theirs. Medical transport companies (not the same thing as an actual ambulance) are out-of-pocket too. Again, a surprise from this same hospital. I hope the Humana/Tricare caseworker is ready for a looooooong phone conversation Tuesday. Thankfully 99 percent of the time it's a short conversation because they say "ignore the statement. Those are generated automatically and are never accurate. Wait until you get an actual bill but don't pay the bill! Call Humana first so we can see what is legit and what isn't." Okay I'm not the most business/finance/legal/medical savvy guy on the planet, but was this whole system designed by deaf, dumb & blind evil circus monkeys? Because this what we should expect to see in a system designed by deaf, dumb & blind evil circus monkeys - who were probably "outsourced services" just to rub our faces in it.

 

[WOODIE13]

I've got some astronomical bills from hospitals, both while on active duty and after I retired for my dependents. Normally it was just the hospital trying to get their money upfront while waiting on the Tricare/CHAMPUS claim to go through. Then I'd get another bill, much lower, then another lower than that one.

All of mine were preauthorized or under emergency conditions, ended up having to pay my co-pay but that was it. Never had to go through the appeal process.

 

[Ruger#3]

Likewise, I have never had to appeal anything. A 55K surgery cost me about 250 bucks, I’m not complaining at all.

 

[WOODIE13]

My wife said they kept sending us adjustments after they got paid by tricare, plus bills from every doctor and specialist she saw, from ER to ISCU stay for @ 10, co-pay was @ $750 in 2015.

Can't remember the amount, getting old sucks

 

[Oldstick]

on last colonoscopy as the prepped me on the table, before the sleepy time meds, I asked that anyone not covered by my plan leave the room and that I would pay if they were out of network.

they looks unamused. The parts of their faces I could see around the masks. It was serious. Not sure how much legal weight it would have carried. Probably none. But it was said. I didn’t choose anyone in the room specifically, except the doctor and sketch artist

That's my exact feeling. Except for me I am NOT going to pay for any out of network balances when they invite every tom, dick and harry into the room to bill me, and I am NOT going to pay for any procedure denied by my insurance, such as when the medical team fails or refuses to contact the insurance to obtain the required approval for the procedure.

 

[oldfella1962]

I've got some astronomical bills from hospitals, both while on active duty and after I retired for my dependents. Normally it was just the hospital trying to get their money upfront while waiting on the Tricare/CHAMPUS claim to go through. Then I'd get another bill, much lower, then another lower than that one.

All of mine were preauthorized or under emergency conditions, ended up having to pay my co-pay but that was it. Never had to go through the appeal process.

Thanks for the info! Yes hospitals trying to get their money up front before the dust has even settled makes sense. Probably why more than one Humana/Tricare person has told me to never pay a bill that seems fishy. Companies often try to get more than they are allowed to claim whether from a patient or their insurance company. The thought of a 700,000 dollar medical bill is insane. I would very likely never even live long enough to pay it back if every dime of my income went to paying down the bill.

 

[oldfella1962]

That's my exact feeling. Except for me I am NOT going to pay for any out of network balances when they invite every tom, dick and harry into the room to bill me, and I am NOT going to pay for any procedure denied by my insurance, such as when the medical team fails or refuses to contact the insurance to obtain the required approval for the procedure.

Yes indeed it is very unscrupulous to "set you up for failure" by not communicating between the doctors, the patient, and the insurance company. What's really upsetting is the largest part of the 700 grand bill came from a hospital that the military hospital is partnered with, and patients are sent there by default when (if) they survive the ICU of the military hospital! Point being if they are authorized to be treated at the military hospital by virtue of being vetted as having Tricare, obviously the hospital they are partnered with accepts Tricare too.

As for "outside the network" medical people & procedures, my wife was in a coma when she underwent much of this! She was not have the ability to question what was going on or who they worked for. I did get a few phone calls from the various hospitals to get my permission
for blood transfusions & whatnot, but only because certain religions don't allow them or something, so by law they have to ask if the patient or their caretaker is okay with it.

 

[oldfella1962]

Update! The majority of the 700K claim that was denied might have an explanation. The billing department of Hospital X used the wrong code number and hospital name! We'll call it "Hospital X." Anyway, the billing department from Hospital X - physically located in Hospital X - used the code number and name for Hospital Y. Both hospitals start with the letter "S". Maybe there is a pull-down menu or something, who knows? But Hospital X did not recognize its own name and code number, thus using the name & code of Hospital Y instead. Tomorrow I am taking the 17-page statement up to the military base to see the Humana advisors and see what they can do to rectify this.

Bottom line this being Augusta Georgia I am not surprised! This is the typical level of competence and lack of attention to detail that I have come to expect.

 

[WOODIE13]

Update! The majority of the 700K claim that was denied might have an explanation. The billing department of Hospital X used the wrong code number and hospital name! We'll call it "Hospital X." Anyway, the billing department from Hospital X - physically located in Hospital X - used the code number and name for Hospital Y. Both hospitals start with the letter "S". Maybe there is a pull-down menu or something, who knows? But Hospital X did not recognize its own name and code number, thus using the name & code of Hospital Y instead. Tomorrow I am taking the 17-page statement up to the military base to see the Humana advisors and see what they can do to rectify this.

Bottom line this being Augusta Georgia I am not surprised! This is the typical level of competence and lack of attention to detail that I have come to expect.

Must've been a Friday or Monday...getting ready to get drunk or just coming off one

Good luck

 

[chiefbaron]

It is a discovery process almost every week!

Retired military living in White Co - 3-1/2 hrs to Augusta, 4 hrs to Warner-Robbins, 4 hrs to Huntsville. So I am living the nightmare of TriCare in a remote local since the wife had a stoke 364 days ago, then a 2nd stroke, then a silent heart attack, now in heart failure. So far, 175 claims in the TriCare portal. I check it most days to see if any new claims have been submitted. So far, TriCare billed - $505,823.15, my cost is $12,774.35. That does not include pharmacy cost for meds - a whole different nightmare if you don't have access to an MTF.

It's like being on active duty again in Div Ammo Ofc tracking bullets.

Some good URLs:
Surprise Billing Protection Form - info for subcontractors/non-hospital providers
https://www.cms.gov/files/document/...ency-facilities-regarding-consumer.pdf#page=5

Lookup NPI Numbers from the NPI Registry - info on any Dr or Med Facility (TriCare wants NPI # for providers)
https://npidb.org/

Current Procedural Terminology - look up billing codes
https://www.aapc.com/codes/cpt-codes-range/

Prescription Drugs | TRICARE
https://tricare.mil/formulary

 

[oldfella1962]

It is a discovery process almost every week!

Retired military living in White Co - 3-1/2 hrs to Augusta, 4 hrs to Warner-Robbins, 4 hrs to Huntsville. So I am living the nightmare of TriCare in a remote local since the wife had a stoke 364 days ago, then a 2nd stroke, then a silent heart attack, now in heart failure. So far, 175 claims in the TriCare portal. I check it most days to see if any new claims have been submitted. So far, TriCare billed - $505,823.15, my cost is $12,774.35. That does not include pharmacy cost for meds - a whole different nightmare if you don't have access to an MTF.

It's like being on active duty again in Div Ammo Ofc tracking bullets.

Some good URLs:
Surprise Billing Protection Form - info for subcontractors/non-hospital providers
https://www.cms.gov/files/document/...ency-facilities-regarding-consumer.pdf#page=5

Lookup NPI Numbers from the NPI Registry - info on any Dr or Med Facility (TriCare wants NPI # for providers)
https://npidb.org/

Current Procedural Terminology - look up billing codes
https://www.aapc.com/codes/cpt-codes-range/

Prescription Drugs | TRICARE
https://tricare.mil/formulary

Thanks for the links! It's good to be able to have something to help my disputes - or even ballpark what kind of "out of pocket" money I might owe in the near future. I wouldn't want to be in your shoes living so far from any Tricare authorized facilities. Augusta is knee-deep in medical care and while not all the facilities are "in the network" many are, and some are partnered directly with the military & VA hospital. Many military doctors, nurses and techs moonlight at several different hospitals and you never know when you'll run across somebody who knows or remembers you.
But I do spend a lot on drug "co-pays" because the military pharmacy has limited hours and often don't carry certain drugs - or they mess things up and are unwilling to communicate with doctors or fix problems or even answer questions.

 

[WOODIE13]

Thanks for the links! It's good to be able to have something to help my disputes - or even ballpark what kind of "out of pocket" money I might owe in the near future. I wouldn't want to be in your shoes living so far from any Tricare authorized facilities. Augusta is knee-deep in medical care and while not all the facilities are "in the network" many are, and some are partnered directly with the military & VA hospital. Many military doctors, nurses and techs moonlight at several different hospitals and you never know when you'll run across somebody who knows or remembers you.
But I do spend a lot on drug "co-pays" because the military pharmacy has limited hours and often don't carry certain drugs - or they mess things up and are unwilling to communicate with doctors or fix problems or even answer questions.

One more added, let me know if you have problems and I'll tune him up.

 

[Ruger#3]

Express Scripts recently added a specialty drug partner Accredo. Your Doc sends scripts electronically to Express Scripts as usual but if it’s a specialty drug Accredo will fill it. This offers more flexibility to Tricare pharmacy users. I take one drug that would be shipped from the manufacturer if not for Express Scripts.