With the help of Frank Lobb, author of The Great Health Care Fraud and Too Big to Be Legal, AAPS has developed suggested letters for insured patients to send in case they get a huge bill from an out-of-network “provider” called in by a hospital, such as the $117,000 bill from a “drive-by” assistant surgeon (NYT 9/20/14). Use the comment box at the bottom of the page to share your reactions to these letters, other letters you have used, and the outcomes.
Suggested responses of insured patients to unexpected, outrageous bills.
(It is important to send within 30 days.)
Letter #1, to Insurer
To: The Insurance Company’s General Counsel
cc: The Out-of-Network Billing Entity
The Hospital Involved
State Insurance Commissioner
The attached bill has me very concerned because it appears to violate the terms set forth in your State-approved Provider Agreement with (hospital’s name). Please note the following facts:
- As an enrollee in in your company’s health plan, I am a third party beneficiary of your Provider Agreement with (hospital’s name).
- Under the terms of your Provider Agreement and my health plan, I am “assured” coverage if the care is pre-certified and rendered in an in-network hospital, which (hospital’s name) clearly is.
- Under the terms of your Provider Agreement and my health plan, (hospital’s name) has agreed to render only pre-certified in-network care or surrender any and all right to bill your company or me for the care.
- (Hospital’s name)’s use of an out-of-network provider not specifically approved by your company and me prior to the rendering of care violates both the spirit and the clear language of your Provider Agreement as well as my health plan.
(Hospital’s name) is contractually required to gain your approval prior to rendering any out-of-network care or to provide the care free of charge. And, as a third-party beneficiary to your State approved Provider Agreement with (hospital’s name), I have every right to insist that you enforce the terms of the Agreement by making the hospital accept sole responsibility for the attached bill.
In the event that you disagree with this interpretation of your Provider Agreement, please send me a copy of the agreement.
I await your reply,
Signed Enrollee
Letter #2 to Physician or Other Billing Entity
To: The Out-of-Network Billing Entity
cc: The Insurance Company’s General Counsel
The Hospital Involved
State Insurance Commissioner
Please redirect your bill to (hospital’s name) for payment. Unless you can show that my insurer pre-certified the out-of-network care stated in your bill, this cannot be my bill or even that of my insurer. Your bill can only be the direct financial responsibility of (hospital’s name) as the one that authorized your practicing within their facility and outside the obligation created by the clear language of the Provider Agreement that (hospital’s name) signed with my insurance company, and which the State approved.
I await your reply.
Signed Enrollee
Letter #3 to the Hospital
To: The Hospital Involved
cc: The Insurance Company’s General Counsel
The Out-of-Network Billing Entity
State Insurance Commissioner
Please note that any assertion that I am responsible for charges my insurer fails to pay violates the State-approved Provider Agreement you signed with my insurance company. Furthermore, you must be aware that this Agreement obligates you to stay in-network and to obtain my insurer’s pre-certification for all non-emergency care, or provide the care free of charge to both my insurer and me. And, since it is my understanding that you knowingly failed to pre-certified the care covered by the attached bill, please acknowledge that it can only be your bill, not mine, and take the necessary steps to resolve it with “your” out-of-network provider.
In the event that you disagree with this interpretation of your Provider Agreement, please send me a copy of the agreement.
I await your reply.
Signed Enrollee
