GeoffM

TL;DR version: Authorisation received to see Dr. X, signed in, paid for X, got Dr. Y instead. Billed by Dr. Y as if uninsured. Is this legal?

Full version: Our insurance requires referrals (EPO) so duly got authorisation letter to see Dr. X. Come appointment time I signed in on Dr. X's sign-in sheets and (co)paid to see Dr. X. Halfway through the consultation I notice I'm not seeing Dr. X at all. Confirmed afterwards that Dr. X is on vacation and I saw Dr. Y. Dr. Y was an idiot, not listening to answers and gave a 4-minute diagnosis that did not agree with my previous 3 doctors and which normally requires tests to diagnose. Nobody told me I was seeing a substitute.

Later I was billed in full (as if uninsured). Hand delivered a letter to his office and got the receptionist to sign that she'd received it. No response. Sent a formal appeal by certified mail to the billing department. No response.

A year later I went to book an appointment elsewhere and found I couldn't as my bill was "heading for collections". Phone them up and discover it's still the disputed bill from a year ago. Ask why nobody replied. No answer given. Ask why it was denied. Something about the diagnosis being not covered by insurance - the diagnosis that nobody else agrees with, from the doctor I never wanted to see, for an office visit that was fully authorised in advance by this same billing department. I can understand further treatment being denied on the basis of that initial visit, but not the initial visit. Chicken and egg, sort of.

I suspect the issue is actually that I saw a doctor I wasn't authorised to see (and entirely unbeknownst to me). But they can't understand that, all they see is this diagnosis not covered.

Since I've exhausted the doctor's office and the billing department, what next? There seems to be another level of insurance which might be the EPO stuff not done in the hospital itself (fairly small). Then there is Anthem for PPO (out of network I suppose) but it shouldn't have reached that level. Mind you, the co-pay for Anthem is still 1/10th of the bill I received from this EPO doctor.

Sorry if that's confusing. I'm confused with this hospital, its billing department, the other company's name, and the Anthem on top of that.

Pulaski

Sounds like it's time for a consultation with a lawyer and letter from the lawyer. From what you say, it sounds like there are at least a couple of reasons to argue breach of contract.

In any case, if you contracted specific service from Dr X, and Dr Y showed up instead, I think the contract was void ab initio.

GeoffM

That would be the logical conclusion - not allowable to pay for one thing and receive something different. But I've learned that US health care is anything but logical for even the simplest things.

Just last week I had a "discussion" with a pharmacist('s technician) about a prescription I handed to her. "I need to get authorization from your doctor first". But you're holding a prescription signed by that doctor just half an hour ago which is authorisation for you to dispense that drug... and you're going to call the phone number I just gave you, hope you're going to speak to her and not a receptionist pretending to be her, and get a verbal authorisation that corresponds with the anti-counterfeit prescription paper you're holding... (Yep, she did). Really is a case of "jump" and "how high".

thinbrit

File a complaint with the state board:
The Medical Board of California
Your specific circumstance may not be handled by the board, but I suspect the hospital will still have to take time to respond to the complaint.
Use this form:
http://www.mbc.ca.gov/forms/07i-61.pdf

Redwing

Agree 100% with this. I have done this in the past, and you would be surprised how quickly things get resolved.

scrubbedexpat091

I had that happen once, all it took was a call to insurance company and they resolved it, surprised the insurance company is being so difficult, guess times have changed.

But do as suggested file a complaint, that will probably get it resolved.

Hanco

I was billed as if uninsured for the full costs of treatment. I spoke with the billing department and they agreed they did have insurance details. They fixed it, and I paid only what was due, but a few months later a letter from collections. Had to send them evidence I had paid in full. Healthcare is horrendously complex here (the building/facility bill, specialist bills, doctor, nursing, blood work, scan/X-ray...) All separate invoices, all coming separately to you, at various times after treatment. Don't get ill

GeoffM

Update: Went for a follow-up for something else and was told my account was blocked due to non-payment. Went to the billing office in person 5 minutes away, explained to the worker the issue, she went out back, came back a few minutes later and said "What problem? It was sorted a month ago". Also received a statement saying same. Phone call to the person who 10 minutes ago said account was blocked and she confirmed it was no longer blocked. Magical mystery billing.

Still not had a single reply to the three formal appeals. Pretty crap really. Wife is trying to change employer and thus health insurance provider as the one and only plan is poor quality.

Asg123

I agree with the others that you should complain. As you say it's a very bad and confusing system. I had an issue and spent months trying to resolve it but it was only when I finally complained that the issue was addressed. I filed with a different place from the other posters: Help Center, California Department of Managed Health Care (1-888-466-2219).