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CalAttorney2, Attorney
Category: Legal
Satisfied Customers: 10244
Experience:  Civil litigation attorney for individuals and businesses.
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My wife and I live in San, CA. She is facing a medical

Customer Question

My wife and I live in San Jose, CA. She is facing a medical billing dilemma now - A medical lab billed her $4,465.00 total, insurance company only covered $1,545, so medical lab asks her to pay the rest $2,919. She checked with insurance co. and customer service staff said the reason why she has to pay such a high amount is because the med lab used is a out-of-network provider, she was supposed to request in-network service provider when she first checked in at hospital, according to a written reply from insurance company later. Currently the med lab is pushing payment aggressively and even threaten to forward the case to collection agent. The potential financial responsibility of $2,919 or in that proximity was never mentioned when she first checked in at hospital for the bronchoscopy operation, she only paid the copayment requested by hospital check-in staff.
My question is that it was the first time my wife underwent such a medical operation named bronchoscopy, and a 2-hour medical operation ended up with an incident called pheumothorax and an emergency surgery to fix that. My wife had never undergone any surgery before throughout all her life and certainly had no knowledge to request in-network provider for the biopsy, as a un-experienced patient she thought hospital check-in staff asked for her insurance ID and should naturally send her tissue samples to an in-network test lab plus she was in full anesthesia during the emergency surgery, the biopsy samples were eventually sent to this out-of-network medical lab somehow, and now everything became reality and she became an easy prey for this bill. Does she stand a chance at all to appeal from insurance company (or to win through small claim court?)? Would it be better to look for dispute resolution services or to look for a medical attorney?
Thanks for listening and your advice is greatly appreciated.
/W. Lin from San Jose, CA
21:45, 10-13-2015
Submitted: 1 year ago.
Category: Legal
Expert:  CalAttorney2 replied 1 year ago.

I am sorry to learn of your wife's situation.

If the bill is coming from the hospital, ask them (the hospital's billing department) for a "Payment Assistance Application" this is how most billing issues such as this are resolved (they should tell you about it, but not all billing agents will). It is a needs based application, but most patients will qualify. You have already submitted your bill to your wife's health care insurance company, and you will likely be able to complete the remainder of the application in less than 15 or 20 minutes.

The billing department will process the application and it will either drastically reduce, or entirely eliminate, your wife's bill.

(Most other medical services will have similar programs, but all California Hospitals participate in this program (it is Government money that funds the service).

Customer: replied 1 year ago.
Hi, WilliamThanks for prompt reply. Unfortunately, the bill came from a medical lab called South Bay Path Medical Assoc., it is a medical lab, not a hospital, I'm not sure whether it was the hospital admin. staff sent my wife's lung tissue samples to this lab or it was sent under our family doctor's direction, will a test lab have the provision of "Payment Assistance Application" just like a hospital? If not, then what's next step?/Wen.
Expert:  CalAttorney2 replied 1 year ago.

Start with the Payment Assistance Application (at least ask about it - both with the hospital and with the lab).

If that doesn't work, then you are going to need to start going through the actual paperwork/contracts that you (or your wife) signed when she received her services (at the time of check in with the hospital). This is going to give you the legal obligations for both you and the hospital (as well as third party providers) for billing and payment responsibilities.

Unfortunately the ultimate payment obligation is going to fall on you and your wife, but do read the contract carefully, if you can identify that the hospital was supposed to utilize a different provider and failed to do so, you can approach them with the specific clause identified, and negotiate their responsibility for this payment.

If you find that you are ultimately responsible for the bill, and there is no other responsible party, then you can try negotiating a reduction in the bill with the provider directly.

When trying to settle a debt, creditors generally prefer lump sums over payment plans. They are often willing to accept an amount less than the full debt (the trade off is that they get a quick payment and don't have to worry about ongoing collection costs or administration). If you do not have the ability to offer a lump sum for something the creditor will accept (some will accept a small portion, while others want close to the full amount), you can try a payment plan, these are less satisfactory to the creditor (especially if they have a lien on your property already), but if you are willing to offer something with a reasonable chance to get the creditor a large amount of their debt back, you are likely to get them to accept it.

Whenever working with a creditor, make sure that you keep your communications in writing (if you speak to someone by phone, promptly send a confirmation letter to summarize your conversation), as this will help to ensure that there is no confusion later on, and you will be able to enforce your settlement against any future collection efforts.

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