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Seriously confused and in need of help please!!


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I was admitted to the emergency room at the beginning of April 2012 by my grandparents down in Nevada (I lived in Washington before and after this incident so that's where my insurance is through- First Choice Health) for suicidal ideation and an anxiety attack. After being held there for a couple days I was moved to a psychiatric hospital for an involuntary psychiatric stay.


We had met our deductable for the year because of these stays and after that my mother and I arranged payments with them while waiting for insurance to chime in but it seemed to be taking longer than normal. I soon decided to call the hospital and they told me that the insurance wasn’t responding to their claim.


When I called insurance, they said that they never received anything from that time period. For the next few months I continued to check in with both ends but there was obviously a continued miscommunication because nothing has been taken care of. We tried conducting three-way calls to work it out and every few weeks I attempted to get an update of the status but it all has been unsuccessful.


At the end of December 2012 I called the hospital to give permission for my mother to deal with further inquiries while I went on a volunteer trip, but when I returned, my mother informed me that they had been refusing to speak with her because “their records had been wiped.” They sent me to collections, but when I called the agency and explained, they dismissed the claim.


A few more months of bills in the mail and now I have been sent to Grant & Weber, Inc., another collection corporation. Now when I try to call the hospital to figure out what is going on, they won’t even speak to me. They ask, “Can I put you on hold for a minute to check something?” and just like that, after already waiting an hour on hold with them, they forward me to this agency without even hearing what I have to say. Grant & Weber has since threatened to forward my account to their attorney even though I clearly have insurance that is supposed to be paying for my medical bills. The last time I called to dispute the bill they said something about a $60,000 bill that my insurance has already paid $38,000 towards and that's all they wanted to pay. I have absolutely no idea where these random numbers even came from and the representative didn’t stay on the line long enough to explain anything to me.


I eventually was able to get a register of bills with the diagnostic codes from the hospital that I included in a letter I sent to my insurance company directly since they has failed to do so. They wrote back saying that it's too late to make a claim. Isn't that what I was trying to do the entire time?? I have no idea what is going on here. I'm only 20 years old, I work and go to school, and I don't have the energy to deal with this. When I checked my credit score recently it said that I have around $3,200 in collections by Grant & Weber and trust me, it's completely killed my credit.


I apologize for the huge chunk of text, but I could use any advice on this matter.


The insurance company and the hospital apparently have no records of these many calls I had been making trying to fix this. What am I supposed to do? So far we've payed over $6,000 towards an entirely unecessary bill. I don't have any more money to pay this bill, nor should I have to considering I HAVE insurance and my deductable was met. Am I in the wrong?

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If I had not spoken to someone from Washington State Office of the Insurance Commissioner : http://www.insurance.wa.gov/about-oic/what-we-do/advocate-for-consumers/consumer-advocacy/ I would probably start there to find out what my rights are and how I can best assert them.


I would stay off the phone with useless entities like collectors. They don't give a hoot whether I owe anyone a dime they just want what they want.


Obviously phone calls to other parties have not worked well as described here. I would want to send immediate follow up letters memorializing the conversation after speaking to them or preferably do all my communications in writing.


I believe WA is a two party state making it more difficult than some states in regard to lawfully recording phone calls.

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 I don't have any more money to pay this bill, nor should I have to considering I HAVE insurance and my deductable was met. Am I in the wrong?


Having insurance does NOT mean that once the deductible is met that coverage is 100%.  Three things may be affecting the limited coverage and payment.


1)  The hospital in Nevada more than likely is out of network and therefore care is reimbursed at a reduced rate.  If they are not even under contract to your plan then the coverage could be even worse.


2)  Mental health coverage is typically 50-60% of the allowable charge after the deductible is met NOT 80% like medical care.  Some things like physician fees and medications are covered at a higher rate but the hospital stay and treatment are typically 50%.


3)  You exhausted the amount of care for mental health treatment for the plan year.  Most insurance plans even the best ones have a cap on how much money they will pay for each patient during a plan year for mental health care.  If you had used some of yours already or it was already exhausted that would limit how much of this claim they would pay as well.


If the total bill for the stay in an out of network facility was around $60,000 and the insurance paid $38,000 that would be about right:  approximately 50% coverage for mental health treatment out of network.  The remaining balance is your responsibility even if you already met the deductible depending on the terms of your plan.  You need to see exactly what coverage you had for mental health care and what was paid and why.


Before getting the Insurance Commissioner involved you want to get copies of all the EOMBS (estimation of medical benefits) from the insurance company on exactly what they paid and denied related to this care.  Once you have that in writing you can see if indeed you do owe this facility anything or not because the EOMB will list exactly what your financial responsibility as the insured is.  


Clearly you are very young and do not understand how health insurance coverage works.  I highly recommend you take the opportunity to educate yourself on deductibles, co-pays, co-insurance and how it works with reimbursement.  One thing that you keep saying is "I have insurance and there should be no bill" and that just is not how it works.  As the insured one thing you agree to in your contract with the carrier and any medical provider is that you will be financially responsible for any care your receive that is not covered by your plan.  The more you understand how insurance and health care billing works the less likely you are to have medical bills that take you by surprise.

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