VIRGINIA BEACH
Mary Ann Dockter was sure it had to be a typo.
She had an epidural done for back pain in April 2006. A couple of weeks later, she got a bill from Sentara Healthcare for $753.95. She figured that once it was processed by Cigna, her health insurance carrier, she’d be on the hook for 20 percent of that and expected to pay $150 or so.
A while later, Dockter learned that Cigna had paid $2,166.40 to Sentara for the $754 charge but that she, somehow, still owed $641.60.
“I said, 'Something’s wrong. This is just kind of screwy,’” Dockter said.
After repeated calls to Sentara and Cigna, she said, she was assured that, no, everything was as it should be.
Except for Sentara and Cigna, “everyone we’ve talked to said it doesn’t make sense,” said Gerry Wardzinski, Dockter’s husband. “How can you get more money than what you billed and expect us to pay on top of it?”
So Dockter and Wardzinski refused to pay the bill. It wasn’t the money – the comfortably retired couple could afford it – it was the principle of the thing, they said.
Eventually, Sentara sued Dockter for nonpayment, and on Thursday, she was in Virginia Beach General District Court.
“I thought there was a mistake, and I tried to solve that mistake … for two years,” Dockter told the judge. “I just assumed there’s a mistake because this was way out of line for a $700 procedure.”
In court, Sentara’s lawyer Robert Bray explained how it worked out that Dockter owed what she owed.
Health systems have contracts with insurers about what the insurer will pay for a given procedure. While the specifics are confidential, Cigna’s contract with Sentara allowed for a “case rate” to be applied. In Dockter’s case, that meant the epidural injection she received was part of a group of outpatient surgeries that were all covered at the case rate of $2,808.
Presumably, while the $753 charge for Dockter’s epidural was only a fraction of the case rate, there are other, more involved procedures that Sentara would bill significantly more for. Regardless, Cigna would pay $2,808 and, in theory, it all comes out in the wash in the long run.
In Dockter’s explanation of benefits from Cigna, it shows that a $100 deductible was subtracted from the $2,808. Then Cigna paid 80 percent of the remaining $2,708, or $2,166.40.
Dockter’s policy with Cigna included a coinsurance payment, so what she owed to Sentara was then 20 percent of $2,708 – or $541.60 – plus the $100 deductible. That totals $641.60.
Back in 2006, Dockter was expecting to pay 20 percent of Sentara’s $753.95 bill, but instead, she was responsible for paying 20 percent of the contracted amount between Sentara and Cigna.
Dockter and Wardzinski said they understood Sentara’s argument but thought it was wrong and ought to be fought.
“Gerry says not to use the word 'moral,’ but it’s a moral issue to me,” Dockter said.
On Thursday, the judge ruled for Sentara and directed Dockter to pay the bill. After the judgment, Dockter, Wardzinski and Bray – who is Sentara’s chief collection counsel – worked out what was owed for the original epidural and others she’s had since then. Dockter wrote a check to Sentara. Bray then arranged to have the judgment against her vacated so that it wouldn’t show up on her credit history.
Bray said he understood how Dockter and Wardzinski felt.
“It would be frustrating for me if I were in their shoes,” Bray said.
Occasionally, once everything is sorted out between the provider and the insurer, it can have “unexpected consequences for a patient,” he said. “It’s difficult to get a good grasp on what it’s going to cost.”
Bray said he thought he had an ethical obligation to collect what was owed to Sentara from people who are able to pay – in part to help pay for charity or discounted care for patients who are unable to pay the full price.
Dockter’s situation is unusual in that, normally, insurers don’t pay more than the billed charges and often pay less, said Emma Inman, a spokeswoman for Sentara. She added that patients can call the health system to find out what their expected out-of-pocket costs would be for a given treatment. But, she said, the best source for insured patients is to call their insurance carrier, which should be able to give a better estimate and also compare costs among providers.
Cigna did not return two phone calls Friday.
Dockter turned 65 recently and will now be covered by Medicare, which she presumes will not pay so much for an epidural. Court decision aside, she’s happy to be done with the matter.
“This has been an annoyance.”
Nancy Young, (757) 446-2947, nancy.young@pilotonline.com
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perpetuation
..."he thought he had an ethical obligation to collect what was owed to Sentara from people who are able to pay – in part to help pay for charity or discounted care for patients who are unable to pay the full price.
That is the most outrageous thing. Anyone getting health care that is unable to pay should not be getting health care. It’s a perpetual cycle driven by insurers and doctors who refuse to stop treating people are unable to pay. Why should the costs of health care be spread out on people can afford it. The fittest in society should survive over the indigents from reproducing to make more idiotic indigents. America will get weaker and weaker as the day goes on!!
It's called Cost Shafting--er Shifting
People who have insurance pay the tab for people who don't. That's why your health insurance is so high. Between paying for huge lawsuit awards and the cost of medical care for the Medicaid recipients and illegal aliens, the cost of care for the insured has become astronomical. I changed from a 20% copay plan to an HMO because the co-pays had become more than the cost of the monthly premium and it's been a very good thing for me since I have large prescription bills that are totally paid for by the HMO. Cost shifting keeps hospitals in business that are required to provide medical care for illegal aliens and indigents by law. Kick out the illegals and watch your property taxes and health insurance premiums drop drastically--we are paying for their medical care, education, lawyers and incarceration. Enough! Go to www.numbersusa.com and put a stop to it!
There's the law.. and there's common sense......
If I understand correctly, the charge for the procedure was $753. The insurance company paid $2166 AND judge ruled that the patient would have to pay $541 in addition to the $100 she already paid????
The net result is that Sentara was paid almost 4 times the retail price for the procedure.
Since when did insurance companies dictate what a hospital should charge?
This may be a unique set of circumstances, but that sort of court imposed overpayment is just WRONG!
Sentara is a criminal organization
Fact.
Sentara is a pack of thieves.
No, wait... thieves at least have honor.
She should appeal the decision, and have the judge brought up on charges for his idiotic decision.
Sentara ripped her off, plain and simple, just like they have been nearly everyone for years.
If any of us citizens were to do something like this, the same judge would put us in jail.
I agree with the other poster that said to appeal this....
Most of the people here are talking about the lawyer and the insurance company. I fully agree with you but the judge here is the one to blame. He should not have made his decision in favor of Cigna. They must have some leeway in applying the law when they try some punk thug for killing someone and give him a 110 year sentenence and then take off 109 years. The judges are more dishonest then all of the others put together. This lady should appeals this jerks decision and take it to a higher court.
What a ridiculous wording from the Pilot
" Bray said he thought he had an ethical obligation to collect what was owed." If an attorney is representing a client, they must advocate for their client. Bray has no choice once he takes the case. Is the Pilot suggesting that he could choose not the get a judgment. He is only the attorney, the mouth piece. It is Sentara, correctly I may add, that is pursuing the judgment. Did the Pilot actually ask him, the attorney, if he felt he should be pursuing the case? He probably told them that the Ethical Canons of Professional Responsibility for Lawyers say that an attorney must zealously represent his client,and the Pilot reporter got it all confused and wrote it up the way it was written in the article. Really, what a ridiculous statement on several levels.
Just had too say this
"Why are secret contracts allowed?"
And another post refers to insurance as being led by "legalized gangsters."
Guys, I see that insurance companies are an obvious scapegoat, but it is not the source of your pain. All of us are supporting the legal system. It's the lawyers making the money here. Sure Dr.s make a lot of dough as well,but they should. Ask your physician how much his practice puts out per year for malpractice. Many of you are right that the system is broke but place the blame in the right direction. Know where to start.
Please go to www.protectpatientsnow.org
Funny, huh?
I just hit way harder than this. Then I read this quote of Bray's defending his actions as being "ethical" due to this reason:
"in part to help pay for charity or discounted care for patients who are unable to pay the full price."
I wonder when may day will come to be in the latter group? Being the group that is not receiving discounted treatment is getting really diffciult. How many of you have or have thought about going without health insurance due to the cost? Oops! There goes the house!
Funny, huh?
Hey koz
The worker's paradise of North Korea is waiting for you. No greedy capitalism there, just a collective heaven on earth.
Corporate Greed
Banks, Insurance, Oil, and the likes are the Evil that run this world all in the name of GREED. America is screwed up from the top to the bottom. We have fostered a culture of selfish greed and now are going to have to live with the sick-o world that we created. Hell is here on earth, run exclusively by the MONEY CHANGERS!!!!
RE: Hospital
That's not true! As you put it "Hillary care" would cost 3 x's that amount. Sorry, but that simply isn't the truth. I suggest your look into the Health Care Senator Clinton is recommending.
You Doggone Right
Ditto on that, Patty.
Doubled edged sword
They could change the rule that a patient paying a percentage rather a co-pay is charged based on the bill rather than the case rate. That works out good if the original bill was lower than the case rate. On the other hand, the original bill could have been a lot more than the case rate and people would complain about that too.
$$$=insurance
Trying to get a before hand quote on a medical procedure? Good luck! Insurance companies are legalized gangsters! They have become a necessary evil.
hospital
The hospital needs to make money somewhere to make up for the free treatment they give illegals and the uninsured. If you think this is bad just wait til Hillary care. A middle class citizen will pay 3x this rate for the same procedure while the poor will get it for free. That is, if you ever even receive the treatment. I love socialism.
Healthcare
This article shows a sad state of affairs in the medical field. However I have news for the lady about going on Medicare. I was discussing some horror stories that my elderly parents medical treatment with a neighbor who is a doctor. This was a year ago. The doctor's statement to me: "what do you expect they are Medicare patients. You can't expect good quality health care when one is on Medicare. The words have stuck with me ever since Baby boomers look out you are in for a rude awakening.
A travesty of justice.
If we had a single payer health care system, we wouldn't be subject to this type of mindless, outrageous behavior between hospitals and insurance companies.
I think we should just expand Medicare to be inclusive of ALL of our citizens. Let the medical insurance industry go down the toilet. They add no value...just aggravation....when people are at their weakest.
This was a travesty of justice, which I'm sure plays itself out in countless different situations every day.
I'm glad to hear that Mrs. Dockter is now safely enrolled in Medicare.
I wish we all were.
Hillary will fix it! Go
Hillary will fix it! Go Hill! Oh wait, you mean you're gonna make me pay for other peoples health care? Im gonna have my care rationed? Well I dont want that. You folks pay for you own and I'll pay for mine.
no way!!!
I cannot believe that the judge in this case sided with the insurance company. Where did he go to law school? Cigna's argument makes no sense at all. It was THEIR choice to pay Sentara more that the billed amount for her procedure. The patient should only have to pay her portion of the billed amount. Making her pay more is fraud in my opinion. Patients who can pay for their insurance premiums and copays should not be making up the difference for people who can't pay. We pay taxes for that. Maybe Cigna would make more money if they didn't pay almost $3000 for a $750 procedure. This patient needs to appeal this decision. I challenge some young lawyer who wants to make a name for themself to take on this case pro bono. (I think I smell a movie plot here!) This case stinks on so many levels, but the thing I have the most problem with is statement about making those who can pay help pay for those who WON'T. Why are people who pay their own way continuously expected to make up the difference for those who CHOSE not to work. I don't mind giving you a helping hand now and then, but I really resent supporting you for your whole life if you are able to work.
and truth and reason lose again
What ever happened to paying what it actually cost. She paid almost all of the true (and I say true with my tongue in my cheek)cost herself, minus the 100 deductible. With insurance companies like this, why have insurance. Why are secret contracts allowed?
Charity?
So, we're charging you more than you owe, because you need to help pay for the charity cases??? NO corporation will determine how I spend my charity dollars. I will go to jail first.
Cigna's "explanation"?
Cigna's "explanation" is one of the most ridiculous thing I've ever heard. But having personally dealt with Cigna, I know they have many ridiculous explanations. Doctors and hospitals would rather deal with ANY other insurance company than Cigna. When I told friends of mine in the medical community that my company had changed its plan to Cigna, all I heard was "uh oh!"
Sentara Accounting
If you have ever had a problem and called Sentara accounting for explanation, it's a grand exhibition in gobbly-gook! You may as well talk to the first grade at any school. This is a monopoly and they smash you each time a dispute arises. No compassion, no logical explanations, just, "YOU OWE ME!" Now they move to Chesapeake as far away from the hospitals so there are no connection between the two....LOL
I agree with the previous comment
Annoyance sounds like an understatement. Insurance companies & lawyers, are beginning to look like Public Enemy #1 & #2..Sometimes in that order & sometimes reversed......in my opinion. Of course all of that was probably on the insurance contract, if you want to spend a few days analyzing the contract with a college level dictionary & a pair of 3X reading glasses to decipher it.
It's no wonder everyone hates insurance companies and hospitals
With their blind secret contracts that have the insurance company paying susbtantially more for a procedure than the actual charges, and the patient is the one who gets taken to the cleaners and sued. Oh and I just love how the hospital's attorney says the hospital needs to gouge those that they determine can pay. What a bucket of .... . Needed services get denied, patients get nickled and dimed to death, and the hospital and insurance company monopolies are making out like thieves in the night. What a racket. I'm with the woman's husband, this is just morally and ethically wrong on so many levels.