Saint Clare's Health System

Review: St. Clare's sent my now deceased mother, [redacted] to its short term care facility, Franciscan Oaks in Denville, NJ following a hospital stay in October 2012. My mother belonged to Cigna HMO which does not pay for out of network facilities without prior authorization. Neither the hospital nor Franciscan Oaks warned us that they were out of network, nor did they seek to obtain prior authorization. My mother was suffering from dementia so did not know what was going on and I was under the belief due to many covered stays with other out of network rehab facilities that all services following a hospital stay were covered. So, I did not know to question them.

They knew to bill Medicare and Cigna HMO. They got paid by Medicare in January 2013 but were denied by Cigna. In March my mother passed away. In July, 9 months after her stay with Franciscan Oaks, she received a bill for $1156. I called and asked them to bill Cigna properly as I thought the stay was covered if following a hospital stay. They then added a service charge of $17.60 when I didn't pay immediately. After the September bill I called Cigna myself and spoke to a manager who explained that the facility knew they were out of network and failed to get authorization and failed to warn us that we would be responsible for 20% of the bill. Therefore, Cigna isn't responsible and neither should we be. Also, the billing office of my mother's physician, Dr. [redacted], concurred with Cigna saying Franciscan Oaks should not balance bill the patient if they fail in their responsibilities. Nevertheless, I sent an appeal letter to Cigna asking them to pay this bill, but again they refused.

I spoke to the person responsible for billing and then her manager, but they would not budge on this bill. Now, they have added another $17.60 service charge for a total of $1190.94. Adding service charges is illegal as well since the patient is deceased.Desired Settlement: I want them to cancel this bill as this is their fault. My mother could have gone to an in network facility had she (we) been warned or they could have tried to obtain prior authorization.

Business

Response:

Dear Representative of the Revdex.com, Per you letter dated January 17th, we are responding to complaint ID [redacted]. The “complainant” (“guarantor”, or “daughter”) claims that her and her deceased mother (“mother”, “decedent”, or “resident”) were not informed prior to the mother’s stay in our facility (“facility” or “Franciscan Oaks”) that Franciscan Oaks is out of network with Cigna. The complainant asserts that if the complainant and her mother were notified of this, they could have gained prior approval from Cigna and Cigna would have paid all charges. Cigna denied payment of the charges, therefore the charges and associated late fees become the responsibility of the resident and her daughter/guarantor. The complainant is disputing the charges and claims that she or the decedent are not responsible for payment because the facility did not inform them that Cigna is out of network. The facility asserts that the decedent (or her estate) and her daughter are fully responsible for the charges and associated late fees. The following conditions of admission to our facility were explicitly explained and agreed to in writing by the resident AND her daughter: • The resident is responsible to pay all charges and is responsible for payment of uncovered services through the use of the resident’s financial resources. The resident will be responsible for all charges and costs due to Franciscan Oaks under this agreement whether or not such claims are honored or paid, in whole or in part, by any third party reimbursement. • Nowhere in the admissions paper work (which was executed by the resident, the complainant and the Facility) did Franciscan Oaks assume responsibility to inform anyone that the facility is out-of-network. Specifically, the resident and the complainant acknowledged that no representation, guarantee, statement or claim has been made by Franciscan Oaks that the services to be provided to the resident will be covered under any insurance policy or program. • The resident and her daughter also specifically acknowledged in writing that they were aware that their insurance would not cover the stay and would personally be responsible. • The service charge is completely warranted as the admission paperwork the resident and the complainant signed fully disclosed that failure to pay would result in late penalties. • The daughter also signed a form personally guaranteeing payment for the mother’s charges. Therefore all charges are valid and completely the responsibility of the decedent’s estate and the guarantor. Franciscan Oaks will continue to assert all its rights to collect payment. If the complainant does not have a copy of the admissions documentation that she signed, she is welcome to request a copy from the facility.

Consumer

Response:

I am rejecting this response because:

I may have signed some paperwork when my mother was admitted but honestly was never given a chance to read it, nor was it explained. I was standing in the room where my mother was staying when some woman, in a hurry, gave me some forms to sign. I really do not have any idea what I signed. All I know is that the other facilities where my mother stayed, I too had to sign forms, but they never balanced billed, so I had no idea that this would happen.