her health insurance paid the bill. Only afterwards, her health insurance company found out the son also had Medicare, which was supposed to pay part of the bill. So they wanted their money back.
The health insurance company had sent my client a bill for some $20,000. They claimed they had tried to get the money from Medicare, but was told by some agency representative that Medicare had already paid it. So, they claimed Polly had gotten the money directly from Medicare and had not used it to pay the hospital bill. They were demanding the entire amount be paid back or they would take further legal action against her.
Don't you just love those threatening letters, especially to senior citizens?
Anyway, she explained she had not received any money from Medicare. If she had, she would have used it to pay the hospital bill. She won't have just kept it and definitely didn't have it now.
She had brought in just about every document she could find or had ever received from anyone involved. It was a decent pile of papers. Seniors are usually pretty good about having all their papers.
So, I took the papers and made copies. I hate killing more trees, but I needed to give the originals back to Polly. I did not want to take the chance I'd lose a document or mess it up. Plus, I like to have a working copy that I can write on and highlight as I go through it. It makes it so much easier to find something later.
Of course, I had to clean off my desk first. I needed space to get a good look at everything.
As I went through documents, one by one, I jotted down questions and thoughts that came to mind. By the time I was finished, I had a list of things I needed to get clarified.
One thing seemed to jump out at me off my list. So, I called Polly.
“As I looked at your papers, I noticed there were a few Medicare statements that were addressed to a state agency instead of you,” I explained. “Can you tell me how that agency was involved?”
“Oh, I forgot about that,” she said. “There was a year or so when that state agency was appointed my son’s representative payee for his social security check. I don’t recall it involving his Medicare benefits though.”
That explained why the state agency was named the addressee. As the rep payee, the state agency was responsible for managing her son’s money. You know, paying his bills and stuff like that.
"Do you know what year that was?" I asked.
"Now that you ask, I think it was around the time my son was in the hospital," she replied.
“Do you recall who his agency worker was?” I asked.
“Heavens, I don’t know if I remember that!” she exclaimed. “Let me think a minute. … I think it was a Ms. Cooper, but I'm really not positive.”
“That’s okay,” I said. “I’m sure I can track down what I need to know.”
Well, that was actually easier said than done.
As often happens when dealing with a state agency, it took me a while to track down the right person. When I finally did, I found that when the state agency was appointed rep payee for Polly's son, they were also responsible for dealing with his Medicare benefits. More importantly, I found out the state agency received a check from Medicare around the time Polly would have gotten the hospital bill. The agency was supposed to use it to pay the bill. But, they didn’t.
The Medicare money was sitting in a state trust account for Polly’s son even though the agency was no longer his representative payee. The worker I was speaking with, of course, couldn’t help me actually get the money released. She told me I had to send a letter to someone higher up on the chain of authority.
So, I did.
I sent the state agency a letter explaining the situation. While it was a generally polite letter, I did end it with the usual threat. Just like the threat the health insurance company made to Polly.
Basically, I wrote that they better “send me the money or I will have no choice but to recommend my client pursue further legal action.”
Not too long after sending the letter, although I don’t really remember the timing, I actually received a check from the state. As I had instructed them in my letter, the check was made payable to the health insurance company. I quickly got it sent to the health insurance company with a letter requesting that it be applied to the bill.
When I told Polly, she was so happy at the thought it was finally over. And, you might think that this would be the end of the story, but it actually wasn’t.
Sometime later, she contacted me to say she received a revised bill from the health insurance company. It alleged she still owed some $3,000 after they adjusted it for the Medicare payment. The $3,000 was apparently for some specific doctor’s services.
Needless to say, Polly was upset. She was afraid she could not come up with that money anymore than she could have if it was still the original $20,000.
I told her to send me a copy of this “revised” bill and I’d see what I could do.
At first I was thinking maybe I’d have to negotiate a reasonable payment plan. But, then I remembered coming across some regulation in my research saying something about limits on doctor’s services. So, I went back to see if I could find it.
It turned out that, at the time Polly’s son was getting treatment, there was a regulation limiting a doctor’s right to mark up his bill. I don’t recall the exact wording. But, it basically said that the doctor could only mark up his bill 100% over the Medicare recognized rate for the particular treatment. And this regulation applied to Polly's son.
How do you like that? They could still charge double! I don’t know what the regulations say now, but it makes you wonder about the whole health care debate, doesn’t it?
Anyway, I relooked at the doctor’s bills. And what do you know.
I discovered the doctor in question had marked up his bill more than 100%. In fact, the
doctor actually marked up his service to 300% over the Medicare approved rate. And the health insurance company paid it in full as billed. At 300%!
And now they were demanding that Polly pay back what they paid. The full amount!
I picked up the phone and contacted the health insurance representative I had been dealing with on this case.
“Let me see if I understand this,” I said. “Your company got a bill from this doctor that was over the 100% limit set by the federal regulation and you paid it, is that right?”
“Yes,” she said.
“And, now you want my client to reimburse you for it because you claim you weren’t supposed to pay it, do I understand this correctly?” I asked.
“Yes,” she said.
She went on to explain to me how it all works. How the federal regulation involved had only been around for about a year and all the doctors were not yet familiar with its limitations. And the health insurance company was cutting the doctors a break by paying the bill as they submitted it. Just until they caught up with the new laws, you see.
“So, let me get this straight,” I continued. “Your company knew about the federal regulation limiting the doctor’s mark up to 100%. And when this particular doctor sent in his bill with a 300% mark up, you just paid it in full, no question. You knowingly allowed this doctor to violate a federal regulation and now you want your money back from my client. You knowingly violated a federal regulation when you paid that bill with a 300% mark up, and you want my client to pay for it now. Am I understanding this correctly?”
“Well, we paid it and …” she said.
“I don’t think so,” I said as I interrupted her attempt at justifying why my client should pay for their illegal actions. I know it’s rude to interrupt someone when they are speaking, but I could not believe she was actually going to try to convince me why my client should still pay it back.
Can you believe the nerve of them?
Now, it was over.
Polly called me again a little while later because she received another “revised” bill.
“It says I owe nothing!” she exclaimed. “Zero! I can’t believe it.”
She was thrilled with what I did for her. Polly went from owing about $20,000 to zero! She was so relieved. And she no longer needed to worry about the health insurance company suing her and taking her house, which was the fear she had lived with for the year she had struggled with this problem on her own.
A happy ending!
One True Case Story:
Details Can Make All The Difference
That guy sounds like he was happy with your service. I once had an elderly client once tell me she was thrilled with what I did for her.
When Polly came to my office, she’d already been dealing with this problem for about a year. And she was really upset. She thought she was going to lose her house over it.
It turns out she had a disabled adult son who was still on her health insurance. Apparently, her son had gone into the hospital for some procedure and