The Investigators

DALLAS (CBS 11 / TXA 21) ― Did one of the country's largest insurance company's get caught trying to shortchange a Dallas family? CBS 11 News reveals how some health insurers get you to pay more - so they can pay less.

It happened in seconds; Camille Privitt slipped down a flight of stairs in her northeast Dallas home. "My feet flew out and I fell [and hit] the middle of my back and hit the corner of the stairs."

Privitt says she heard a crunch in her back and couldn't breathe. Her husband, Hugo, called 911 and within minutes, a Dallas Fire Rescue ambulance arrived. Privitt was raced to the Baylor University Medical Center Emergency Room, where x-rays revealed she fractured three thoracic vertebrae.

But here is where the story gets interesting. A few days later, the Privitt's received a letter from their insurance company, United Healthcare, and got a shock. According to the bill, the Dallas Fire Rescue ambulance was an 'out-of-network' service.

The out-of-network claim means United Healthcare doesn't allow $800 for the ambulance call; it allows $700. They don't allow the $225 cost for the ambulance to drive Privitt to the hospital; it allows $45. And it doesn't allow the $31 fee for the medical supplies that held Privitts' neck in place; it allows $11. Bottom line – the cost shifting forces the Privitt's to pay an extra $156, out of their own pocket, to the City of Dallas.

When Hugo Privitt called United Healthcare to complain he said a representative 'wouldn't explain it' and just said the charge was out-of-network. The representative allegedly told Hugo that he would re-file the claim, but 'didn't expect it to change'.

"What made it more absurd; we are provided insurance through the City of Dallas and receive City of Dallas services," Camille added.

That's right; the Privitt's insurance policy is through the City of Dallas. Hugo Privitt is a former City of Dallas firefighter.

Even after complaining, the Privitt's say United Healthcare wouldn't budge. The company says these are 'reasonable charges based upon what other similar service providers in Privitt's area charge'. The only problem with that is - there is no other similar service in the City of Dallas. Dallas Fire Rescue is the only 911 ambulance service in the city -- and their rates are fixed.

According to Dallas Fire Recue spokesman Ernest Gurule, the city isn't making money on ambulance service. "We are not getting this money to enrich ourselves; it is simply to cover the cost of doing business."

Two weeks after Camille Privitt had her accident United Healthcare claimed it caught the billing error on its own. Their statement said in part, "[We] self-identified the error, corrected it, and paid the claim, including providing additional payment that was owed to our member."

The Privitt's still feel United Healthcare wasn't upfront with them and say they are now worried every time they go to the mailbox. "[We wonder] what are they going to do now?"


Tips to Fight Back:

Dialing For Your Dollars: Call the Insurance Company and demand they clearly explain how they assigned your benefits. Write down the name of the person you spoke with and date/time you called. And most importantly, don't lose your cool. Stay calm and always be respectful. These phone calls are almost always recorded and if you are in for a long battle, the last thing you want is to hear yourself upset on the phone.

Busy Signal: If you're not satisfied with the initial decision, call the provider (doctor or other service provider) and explain the problem. They can help you navigate through the complicated maze of medical terminology and give you the 'buzz' words you'll need to challenge the insurance company. Plus, get them to write a letter in support of your claim – this is very important and will help your case.

Hang Up and Pick Up A Pen: Time to start writing the insurer letters and sending it certified mail, with return receipt. Insurance companies make mistakes too. Maybe they missed something. Putting everything in writing preserves your rights for the future and memorializes your case. Then, if necessary, appeal the decision. Insurance companies have an appeal process letting them review it a second time. Watch the deadlines and file quickly if need be.

Big Guns: Texas is very helpful in resolving issues. Click here for the Texas Department of Insurance's complaint form, or check out the 'Related Links' to the right of this story.

Emergency Room to Court Room: You may think about consulting a lawyer. This can be expensive and you may want to use this as a last resort.

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