Adam Woodrum was on a bike ride with his wife and children on July 19 when his then 9-year-old son Robert fell.
"He cut quite badly and I could tell right away that he needed stitches," said Woodrum.
Because they were on bicycles, he called the Fire Department in Carson City, Nevada.
"You were great," said Woodrum. "They took him to the emergency room on a stretcher."
Robert received sutures and anesthesia at Carson Tahoe Regional Medical Center. He has recovered well since then.
Then came the rejection letter.
The patient: Robert Woodrum, who is covered by the Nevada Public Employees' Benefits Program under his mother's health insurance plan
Entire invoice: $ 18,933.44 billed by the hospital
Service provider: Carson Tahoe Regional Medical Center, part of the nonprofit Carson Tahoe Health
Medical service: Stitches and anesthesia during a visit to the emergency room
What gives: The Aug. 4 Declaration of Benefits Document (EOB) said Woodrum's application had been denied and her patient responsibility would be the total of $ 18,933.44.
After Kid’s Minor Bike Acci … by David M. Higgins II
In this case, it is an all-too-common dance between different types of insurers that should be used to pay a patient's bill in the event of an accident. All sides do their best not to pay. And no surprise for fans of the bill of the month: If insurers can't agree, who will get a creepy bill? The patient.
The legal name for the process of determining what type of insurance is primarily responsible is the transfer.
Could another policy – such as car or home insurance, or employee compensation – be required to pay if someone was to blame for the accident?
Assignment is an area of law that allows an insurer to reimburse costs in the event that a third party is held responsible for the injury or damage in question.
Health insurers say a handover helps keep premiums down by reimbursing them for their medical expenses.
About two weeks after the accident, Robert's parents – both lawyers – received the EOB to inform them of the insurer's decision.
The notice also raised questions to Luper Neidenthal & Logan, a Columbus, Ohio law firm that specializes in helping insurers reimburse "third party" medical expenses.
The Company website boasts that "we raise over 98% of the recoverable dollars for the state of Nevada."
Another August 4th letter soon came from HealthScope Benefits, a large management firm that processes health plan applications.
The claim contained billing codes for care "commonly used to treat injuries" related to vehicle accidents, falls, or occupational hazards. A sentence that was underlined for emphasis warned that the rejected claim would only be checked again after completing an accompanying accident questionnaire.
Adam Woodrum, who happens to be a personal injury attorney, is constantly represented by his clients, many of whom have had car accidents. Nevertheless, it was a shock that his health insurer refused to pay because no third party was responsible for his son's normal bicycle accident. And the denial came before the insurer got any information about whether someone else was to blame.
"It's like denying now and paying later," he said. “They are insured and pay for years, then they say, 'This is being rejected across the board. Here is your $ 18,000 bill. "
When contacted, the Nevada Public Employee Benefits program did not comment specifically on Woodrum's situation, but a spokesman did send information from his health plan documents. She referred questions to HealthScope Benefits as to whether the program policy is to deny claims first and then seek further information. The Little Rock, Arkansas-based company did not return emails asking for comment.
The Nevada Health Plan documents Under state law, the Program may reclaim "any payments made under the Plan" for the breach "from the other person or from any judgment, judgment, or settlement received by the participant relating to the breach."
Matthew Anderson, attorney at the law firm handling the Nevada health plan transfer, said he was unable to speak on behalf of the state of Nevada or comment directly on Woodrum's situation. However, he said his insurance customers are using the cession to recoup payments from other insurers "as a cost-saving measure" because "they don't want to pass high premiums on to members".
Despite consumer ignorance of the term, handover is widespread in the health insurance industry, said Leslie Wiernik, CEO of National Association of Subrogation Professionals, the industry association.
"Let's say a young person falls off a bike," she said, "but the insurer thought," Did someone run him off the street or hit a pothole that the city didn't fill? "
Statistics on how much money health insurers can get back by giving the money to other insurers are hard to come by. ONE 2013 Deloitte Consulting Company StudyCommissioned by the Department of Labor, the handover estimated private health plans could get back between $ 1.7 billion and $ 2.5 billion in 2010 – a tiny fraction of the $ 849 billion they spent that year.
Medical providers may have reason to hope that bills will be sent through auto or homeowner's insurance rather than health insurance, as they are likely to be paid more.
This is because auto insurers will "pay billed fees that are grossly inflated," the attorney said Ryan Woodywho specializes in handover. In contrast, health insurers have networks of doctors and hospitals with whom they negotiate lower payment rates.
Resolution: With his experience as a lawyer, Woodrum was confident that everything would work out eventually. But the average patient would not understand the legal quagmire and may not know how to fight back.
"I hear the horror stories every day from people who don't know what it is, are confused and don't take appropriate action," said Woodrum. "Then you will have a year without paying your bills." Or they fear for their credit and pay the bills.
After Woodrum received the accident questionnaire, he filled it out and sent it back. There was no third party liable, he said. No driver was to blame.
His child just fell off his bike.
HealthScope Benefits reviewed the claim. It was paid for in September, two months after the accident. The hospital received less than half the amounts originally billed based on tariffs negotiated as part of its health plan.
Adam Woodrum and son Robert ride bicycles near their home in Carson City, Nevada on November 7, 2020. (Maggie Starbard for KHN) Credit: MAGGIE STARBARD / KHN
The insurer paid $ 7,414.76 of the expense and the Woodrums owed $ 1,853.45, which was their share of the deductibles and co-payments.
Take away: The bill of the month mantra isn't just about writing the check. But don't ignore the creepy bills from insurers or hospitals either.
It is not uncommon for insured patients to be asked whether their injury or state of health could be related to an accident. On some application forms there is even a box in which the patient can check whether it is an accident.
But in Woodrums' case, as in others, it was an automatic process. The insurer denied the claim based solely on the medical code indicating a possible accident.
When an insurer refuses to pay for all medical care related to an injury, you suspect that there is some type of transfer.
When you receive an accident questionnaire, "fill it out, be honest about what happened," said Sean Domnick, secretary of the American Association for Justice, an organization of plaintiffs' attorneys. Make your insurer and all other parties aware of the actual circumstances of the breach.
This is because the clock starts on the day medical care is provided and policyholders may be required by law or contract to submit medical bills within a certain period of time that may vary.
"Don't ignore it," said Domnick. "Time and delay can be your enemy."
This article originally appeared on Kaiser Health News on November 25, 2020and also on NPR and is Republished with permission. KHN (Kaiser Health News) is a non-profit health news service. It is an editorially independent program of the KFF (Kaiser Family Foundation) that is not affiliated with Kaiser Permanente.