Adam Woodrum and son Robert are preparing for a bike ride near their home in Carson City, Nevada this month. During the summer, Robert had a bicycle accident that resulted in a large bill from the family’s insurer. Maggie Starbard hiding caption for KHN

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Maggie Starbard for KHN

Adam Woodrum and son Robert are preparing for a bike ride near their home in Carson City, Nevada this month. During the summer, Robert had a bicycle accident that resulted in a large bill from the family’s insurer.

Maggie Starbard for KHN

Adam Woodrum was on a bike tour with his wife and children on July 19 when his son Robert, who was then 9 years old, fell.

“He cut quite badly, and I could tell right away that he needed stitches,” says Woodrum.

Because they were cycling, he called the Fire Department in Carson City, Nev.

“They were great,” says 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 Woodrums’ application had been denied and her patient responsibility would be the total of $ 18,933.44.

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 letter informing them of the insurer’s decision.

The notice also directed questions to Luper Neidenthal & Logan, a Columbus, Ohio law firm that specializes in helping insurers reimburse “third party” medical expenses.

The company’s website states, “We are collecting 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 care billing codes “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.

Robert’s bicycle accident resulted in a hospital bill of $ 18,933.44 for sutures and anesthesia. Maggie Starbard hiding caption for KHN

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Maggie Starbard for KHN

Robert’s bicycle accident resulted in a hospital bill of $ 18,933.44 for sutures and anesthesia.

Maggie Starbard for KHN

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,” says Woodrum. “You have insurance and you pay for years, then they say, ‘This is refused down the line. 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 should first reject claims and then seek further information. The Little Rock, Ark., Company did not return email asking for comment.

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The Nevada Health Plan records state that, under state law, the program states that “all plan payments are” for the injury “from the other person or from any judgment, judgment, or settlement received by the participant regarding the injury “can reclaim.

Matthew Anderson, attorney at the law firm handling the Nevada health plan transfer, says he cannot speak on behalf of the state of Nevada or comment directly on Woodrum’s situation. However, he says his insurance customers are using the assignment to recoup payments from other insurers “as a cost-saving measure” because “they don’t want to pass high premiums on to members.”

Despite consumers’ ignorance of the term, handover is widespread in the health insurance industry, says Leslie Wiernik, CEO of the National Association of Subrogation Professionals.

“Let’s say a young person falls off a bicycle,” she says, “but the insurer thought,” Did someone run him off the street or hit a pothole that didn’t fill the city? “

The insurance company’s bill led to a claim that determined what type of insurance is primarily responsible. Maggie Starbard hiding caption for KHN

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Maggie Starbard for KHN

The insurance company’s bill led to a claim that determined what type of insurance is primarily responsible.

Maggie Starbard for KHN

Statistics on how much money health insurers are getting back by giving the money to other insurers are hard to come by. A 2013 study by a Deloitte consultancy commissioned by the Department of Labor estimated that the cession of private health plans in 2010 reclaimed between $ 1.7 billion and $ 2.5 billion – a tiny fraction of the $ 849 billion that they spent this 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.

That’s because auto insurers “will pay billed fees that are highly inflated,” says attorney Ryan Woody, who 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, he says, the average patient probably doesn’t understand the legal quagmire and may not know how to fight back.

“I hear horror stories every day from people who don’t know what it is, are confused and don’t take appropriate action,” says 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.

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 is don’t just write 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 the case of the Woodrums, 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.

No panic.

Woodrum received an accident questionnaire from his insurer, which he completed and sent back to clarify what had happened during the accident. Maggie Starbard hiding caption for KHN

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Maggie Starbard for KHN

Woodrum received an accident questionnaire from his insurer, which he completed and sent back to clarify what had happened during the accident.

Maggie Starbard for KHN

When you receive an accident questionnaire, “fill it out, be honest about what happened,” says 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.

And immediately.

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,” says Domnick. “Time and delay can be your enemy.”

Dan Weissmann, host of the podcast “Ein Arm und ein Bein”, reported on the radio interview of this story. Bill of the Month is a crowdsourced study by KHN and NPR that breaks down and explains medical bills. Do you have an interesting medical bill that you would like to share with us? Tell us about it!