News 4 Investigates: Insured but not covered - KMOV.com

News 4 Investigates: Insured but not covered

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ST. LOUIS, Mo. (KMOV.com) -- It was a Memorial Day 2014 nightmare Lemuel Clardy will never forget. Clardy was outside with his children when a rain storm approached. His attempt to open a stuck door to go inside went terribly wrong, “my hand went right through the glass.” Clardy remembers “it was bleeding everywhere” when he was rushed by ambulance to the emergency room at DePaul Hospital. 

Several hours after arriving at DePaul an on call plastic surgeon arrived and performed surgery on Clardy’s arm. Clardy’s wife Tami met the surgeon, “very good, very detailed best bedside manner.” Tami and her husband received two bills following the surgery, one from the hospital, and a separate bill from the plastic surgeon. The insurance covered the majority of the hospital costs, but the plastic surgeon did not accept any form of insurance. “He never once stated he was a concierge doctor” claims Tami. News 4 reporter Chris Nagus spoke with the surgeon, the doctor confirmed to Nagus he doesn’t accept insurance because he mainly specializes in elective procedures that are not covered by insurance. 

The Clardy’s received a bill from Metropolitan Plastic Surgery for $25,555.00. 

The insurance company paid the Clardy’s $3,344.64, the amount it would have paid to a doctor that accepted insurance. The Clardy’s paid the money to Metropolitan Plastic Surgery leaving a balance of $22,210.36. 

The Clardy’s received an invoice from Metropolitan offering a negotiated settlement of $6500.00 due by June 11th, 2015. If the Clardy’s didn’t pay, the letter stated the full amount “is due and going to collections.” 

“We’re going to lose everything, and that’s just hard to wrap my head around over a medical bill,” said Tami. 

According to Dave Dillon of the Missouri Hospital Association “providers negotiate individually with insurance companies.” Dillon says “there are certain specialties because of the nature of the work they do that would most likely be outside the insurance system, for example dermatology or plastic surgery.” Dillon believes the Clardy’s situation is unusual, “I think there’s an opportunity, although a small one for this to be a problem and I think if we found a case, it’s an extreme outlier.” 

News 4 contacted DePaul Hospital about the Clardy’s situation. According to Tami Clardy the hospital agreed to pay the surgeon’s 6500.00 fee after News 4 intervened. The hospital provided a statement saying: 

“At SSM, our goal is to provide the best care possible to all who seek our services regardless of their ability to pay. Similar to other hospitals, we rely upon independent physicians and specialists in the community to ensure appropriate medical coverage. These physicians manage their insurance contracts independently, and at times their contracts and payment requirements differ from our hospitals. 

While HIPAA privacy laws prevent us from commenting on any specific patient information, we understand that medical billing can be complex. This is why SSM provides financial counselors to do whatever we can to assist patients in navigating this process.” 

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