Over my out-of-pocket maximum and STILL getting bills

BPXDomino

I'm not sure whether to be mad at the insurance company or at the hospital where my surgery was performed, but either way I'm frustrated that I have to experience a financial burden with everything else that is going on.

My surgery was July 17th. The hospital called me the day before for prepayment of my portion of the co-insurance - I was no where near my out-of-pocket max at the time, but this bill certainly brought me very close to the max quickly.

Since surgery has occurred, I've had so many bills come after the hospital bill - the surgeon's bills, the other expenses that come with surgery, other smaller doctors appointments, and now, of course, bi-weekly chemotherapy treatments. I very quickly hit my out of pocket max after surgery... but the problem is that Cigna has not processed the hospital bill... and here we are two months later... but they keep processing all of these other "smaller" bills (trust me, they are not that small), so they haven't acknowledged that I've paid my out of pocket maximum yet, and I keep getting billed for these other appointments when all of my money is really tied up in that hospital bill I already paid!!

I've called Cigna many times about this now - 8 or 9 times - to ask what's up, to find out when they are planning to pay this, to BEG them not to process the other smaller bills until that one is complete so the record shows I've hit my max, and I can get my hospital refund before needing to pay these other bills, and... nothing. All of the customer support representatives I speak with act surprised that the bill hasn't been paid yet, as it is well beyond the usual timing to pay, but they haven't offered any helpful resolution. They keep blaming the hospital for taking payment up front (but then also acknowledge that many hospitals do require upfront payment!) And it seems they are just going to keep processing these smaller bills, so every time I go to the doctors, I've got another copayment due.

What can I do at this point? Do I need to get a lawyer involved?

gb2115

That's stressful. Not sure about the lawyer, their fees are probably going to cost a whole lot more than that.

So Cigna isn't being helpful. Have you asked to speak to a supervisor there? Is there a social worker at your oncologist's office who might be able to help you navigate this? I imagine there's a way to get the $$ back from Cigna if you end up overpaying on your out of pocket. That out of pocket max is a negotiated thing with whoever provides your benefits. So there's got to be a way to fix it later. Like, you've paid a bunch of things, but when Cigna comes and says that you've met your out of pocket when the hospital claim clears, but you have a receipt showing you paid that well in advance...they should be able to reimburse you for that. I don't know how to do that, but I think Cigna would HAVE to make that right.

BPXDomino

Thanks, I agree I don't really think I can bring a lawyer into the mix. I do know I will eventually get those hospital fees refunded (the entire amount) but it won't happen until Cigna settles that claim, and there just seems to be no rush on their end to settle it. So I know relief will come at some point, it's just super frustrating right now as the bills keep coming when that's the last thing I should be worried about.

Lula73

Call Cigna and make the request again and set a deadline (like by this Friday). Tell them if they havent processed it by then you will be contacting the state insurance commissioner for assistance in getting Cigna to pay the bill. The copay will still be requested at a dr visit as they don’t check to see if you’ve met your maximum yet - you’ll end up with a credit when all is said and done. However those bills you’re getting on the backend? Do not pay those. Wait for the EOB to come, staple the EOB and the bill together and file it. After Cigna pays the hospital bill you can contact them and ask them to review the previous claim they didn’t pay all of and have them pay it. Trust me, they hate to hear that you know you have rights and Are going to contact the insurance commissioner.

JosieO

BPXDomino,

So very sorry to read of this. It is most stressful, and not what you should be dealing with at this time. Similar thing happened to me earlier this year (although not with Cigna), and there were days I was pushed to tears from the frustration. Other days I had what I call a “white hot” anger.

You have been given some good advice, and I would just add a few more thoughts for you:

- I would not spend time and money with a lawyer at this point. As suggested, contact your state’s insurance commission and request assistance. Make it clear that you are being treated unfairly

- call your hospital and see if they can help you. Some hospitals will have representatives that focus on specific insurance companies, especially if they are a dominant insurer in your area. I did this and found someone who could see the issue and got involved on my behalf-helped to get another voice involved

- assume you are already doing, but be sure to keep good notes- dates/times of contacts, names of people (don’t be told their name is confidential-ask for a reference number

- keep asking for more senior people at Cigna. You’re going to catch someone with the authority to make it happen. In a pinch, I would even ask for the public relations office. Be firm.

- finally, DON’T PAY ANY MORE BILLS until this gets resolved. Doctors and treatment centers want you to get the medical help you need. They know you have insurance, so you should not be turned away from treatment.

I am still working on a couple of “old” issues, but I have resolved to not let the stress of it get to me.

Good luck!

gb2115

With future appointments, if you tell them you've met your OOP, they might agree to not charge you at the time of the visit. I did that for the year where I had rads at the beginning and met my OOP by the end of January. Some of the offices were fussy, but agreed. Of course, when they ran the insurance claim, they were getting full payment from the insurance. If Cigna hasn't caught up yet, you could still get a bill later.

That really is a big hassle to deal with. I had an issue with a hospital bill (that I thought we'd paid) ending up getting sent to fake hospital collections. It ended up being ok in the end, but caused me a great deal of unnecessary stress at the time.

BPXDomino

Thanks all for the help. Interestingly enough, the bill finally shows as "paid" today by Cigna... so I called the hospital immediately, but they said they haven't received payment yet. I called Cigna to ask why it is showing as "paid" if it actually hasn't been paid yet, but they said it will take a few days for the check to get to the hospital... here's hoping it gets there quickly and I have no hassles getting reimbursed. At least now I should show as paying my full OOP costs and won't get any more bills in the future.