Health Insurance Experts, Can You Please Tell Me What is Happening Here? (USA)

[Pink Partridge]

I had a stroke last Monday afternoon. I experienced complete weakness on one side and knew immediately what it was. I was alone. I called an ambulance and they got me to hospital quite fast. By the time I arrived, I regained 90% mobility. They did a CT scan and an echocardiogram. Everything was clear. Thank goodness. They then did an MRI and found the scarring of the clot. A tiny little guy about 4mm.

They admitted me overnight to the hospital. I spent the night getting vitals taken about every 5 hours. Everything was perfect. I am just tired now. But will make a full recovery. I feel like I hit the lottery and am so thankful.

I have no underlying causes that would lead me to have a stroke, other than birth control. My sister has had several DVTs, so a few days later they called me at home and said they would like to order for a Factor V blood test. No results yet.

I haven’t received any bills or claims yet, but I do have Blue Cross/Blue Shield. So I was confident I would not have any issues with coverage.

Until today. I received a letter from the insurance company saying that the “request for full admission is denied as not medically necessary”. WHAT!?!? Nice to tell me after the fact.

And it stated that it “may help your doctor to know that we reviewed the request for full admission using the MCG guideline called Stroke Ischemic (ORG:M-83)”

I did look this up. Lo and behold, the MCG does state that “A diagnosis of acute ischemic stroke no longer necessarily indicates a need for inpatient care”.

My dx was exactly named: acute ischemic stroke on my discharge papers.

I immediately called my insurance and they just said “We don’t have any claims from this event yet, so we can’t comment either way”.

So I am looking to the insurance experts here (or others that have experienced this). Will I really not be covered by my insurance? My doctor admitted me. I had no idea it was denied. Why am I getting this denial letter 6 days later?

Please calm my nerves with your knowledge.

 

[Pink Partridge]

Here is a thread I just found with doctors discussing this. I am in shock that this is a real thing. I am very stressed over this.

https://www.reddit.com/r/medicine/comments/12xhzlh

 

[sunshine1178]

The hospital wants to get paid. They will probably re-code the bill and resubmit. You can call them and alert them to the issue, if it makes you feel better.

I really do hate US health insurance.

 

[VandVsmama]

Submit an appeal. It's a formal process that all Medicare health plans are required to follow.

 

[flyingdumbo127]

No advice just and prayers, Pink Partridge! Take care of yourself please. Feel better

 

[Pink Partridge]

Submit an appeal. It's a formal process that all Medicare health plans are required to follow.

But this is insurance through my employer. Not Medicare. Would that make a differance?

 

[VandVsmama]

But this is insurance through my employer. Not Medicare. Would that make a differance?

employer-based plans also have mandatory Grievances & Appeals policies. contact the insurance company and tell them you want to submit an appeal.

 

[Southernmiss]

Standard protocol for insurance companies to deny first then have the patient worry.

Call your doctor and tell them.

I had a relative have a fall at work in front of his boss in June (still hasn't returned to work) and suffer a brain bleeding on both sides of his brain. Spent 10 days in the hospital and 3 weeks in rehab. Workman's comp denied it saying it was not work related.

Doctor and employer 100% backed it up and said it truly was work related.

 

[tvguy]

Submit an appeal. It's a formal process that all Medicare health plans are required to follow.

I may have missed it but there was no mention of her being covered by Medicare. But yes all insurance companies have an appeal process.

 

[MrsPete]

I had a stroke last Monday afternoon. I experienced complete weakness on one side and knew immediately what it was. I was alone. I called an ambulance and they got me to hospital quite fast. By the time I arrived, I regained 90% mobility. They did a CT scan and an echocardiogram. Everything was clear. Thank goodness. They then did an MRI and found the scarring of the clot. A tiny little guy about 4mm.

They admitted me overnight to the hospital. I spent the night getting vitals taken about every 5 hours. Everything was perfect. I am just tired now. But will make a full recovery. I feel like I hit the lottery and am so thankful.

I have no underlying causes that would lead me to have a stroke, other than birth control. My sister has had several DVTs, so a few days later they called me at home and said they would like to order for a Factor V blood test. No results yet.

I haven’t received any bills or claims yet, but I do have Blue Cross/Blue Shield. So I was confident I would not have any issues with coverage.

Until today. I received a letter from the insurance company saying that the “request for full admission is denied as not medically necessary”. WHAT!?!? Nice to tell me after the fact.

And it stated that it “may help your doctor to know that we reviewed the request for full admission using the MCG guideline called Stroke Ischemic (ORG:M-83)”

I did look this up. Lo and behold, the MCG does state that “A diagnosis of acute ischemic stroke no longer necessarily indicates a need for inpatient care”.

My dx was exactly named: acute ischemic stroke on my discharge papers.

I immediately called my insurance and they just said “We don’t have any claims from this event yet, so we can’t comment either way”.

So I am looking to the insurance experts here (or others that have experienced this). Will I really not be covered by my insurance? My doctor admitted me. I had no idea it was denied. Why am I getting this denial letter 6 days later?

Please calm my nerves with your knowledge.

My husband had stroke about a year and a half ago, and he spent a night in the hospital afterward. NO PROBLEM with the hospital payment or the physical rehab that followed. A stroke is extremely serious (though you were extremely fortunate, and I'm very happy for you), and the insurance company is going to have to pay -- they're just trying their luck. They're trying to see if you'll go away quietly. REFUSE.

 

[cvjw]

Nothing to add about the insurance coverage, but factor V runs in my husband’s family. It causes blood clots, so it is good that they are checking for that. Could also explain why your sister also has had some issues - it mainly affects females.

 

[nw6675]

Less than 24 hours is observation, so you were not admitted if less than that. They likely considered anything more than that (an actual admission) not medically necessary, but it sounds like you weren't.

 

[Mirabell Rose]

If you were in a hospital that is in your BC/BS network, they can’t pass charges on to you that your insurance denies. (Yes, there are some optional medical things they can charge but these weren’t optional.) This is because the hospital signed a contract with BC/BS agreeing to this in order to have in network status. You only have to worry about your copays and deductibles.

If you went to a non-network hospital, as an emergency the hospital and insurance company are required to reach an agreement for coverage and again you would only be responsible for copays and deductibles (although if your plan has separate ones for in network and out of network they may use the out of network ones). There is a federal law that was recently passed that requires this.

I know this because my career was in healthcare finance, and had to sign those BC/BS provider contracts.

So, relax. You are covered. The hospital may appeal to your insurance company, they may downcode, but you are covered. It’s enough to have to deal with being ill. Don’t waste your energy worrying on this.

 

[Pink Partridge]

Nothing to add about the insurance coverage, but factor V runs in my husband’s family. It causes blood clots, so it is good that they are checking for that. Could also explain why your sister also has had some issues - it mainly affects females.

I have never heard of it until now. And now that I am researching it, it's difficult to believe that it isn't a test they run before allowing birth control pills to be prescribed.

 

[Pink Partridge]

Less than 24 hours is observation, so you were not admitted if less than that. They likely considered anything more than that (an actual admission) not medically necessary, but it sounds like you weren't.

I was in longer than 24 hours. It took forever to get discharged the next day.

 

[Pink Partridge]

If you were in a hospital that is in your BC/BS network, they can’t pass charges on to you that your insurance denies. (Yes, there are some optional medical things they can charge but these weren’t optional.) This is because the hospital signed a contract with BC/BS agreeing to this in order to have in network status. You only have to worry about your copays and deductibles.

If you went to a non-network hospital, as an emergency the hospital and insurance company are required to reach an agreement for coverage and again you would only be responsible for copays and deductibles (although if your plan has separate ones for in network and out of network they may use the out of network ones). There is a federal law that was recently passed that requires this.

I know this because my career was in healthcare finance, and had to sign those BC/BS provider contracts.

So, relax. You are covered. The hospital may appeal to your insurance company, they may downcode, but you are covered. It’s enough to have to deal with being ill. Don’t waste your energy worrying on this.

I needed to hear this. Thank you!

(I was in network, BTW)

 

[EACarlson]

Wait until you get an actual bill before worrying about anything. It's quite possible that the hospital and the insurance company work things out for themselves before the actual bill gets to you.

 

[#1hoosierfan]

In April 2022 I was going thru chemo and became very short of breath. Getting up off of the couch to go to the bathroom, and I was winded. I called my oncologist and they sent me to the ER because they susupeced pulmonary embolism..... not uncommon with chemo treatment. They did testing and it showed two pulmonary embolisms in my lungs and I was admitted. Spent 3 days in the hospital on IV medication.

A month or so later I got a bill for the entire hospital stay. I want to say it was something like 20 or 30 thousand dollars. Insurance stated I did not present with symptoms that would typically include a necessity for inpatient care (like coughing up blood.) I panicked and called the insurance company. The hospital billing department got involved too. It was quickly taken care of and my portion was zero ( I had already met my high deductible.)

 

[snowwite]

Quote from Pink Partridge
"I had a stroke last Monday afternoon. I experienced complete weakness on one side and knew immediately what it was. I was alone. I called an ambulance and they got me to hospital quite fast. By the time I arrived, I regained 90% mobility. They did a CT scan and an echocardiogram. Everything was clear. Thank goodness. They then did an MRI and found the scarring of the clot. A tiny little guy about 4mm.

They admitted me overnight to the hospital. I spent the night getting vitals taken about every 5 hours. Everything was perfect. I am just tired now. But will make a full recovery. I feel like I hit the lottery and am so thankful.

I have no underlying causes that would lead me to have a stroke, other than birth control. My sister has had several DVTs, so a few days later they called me at home and said they would like to order for a Factor V blood test. No results yet.

I haven’t received any bills or claims yet, but I do have Blue Cross/Blue Shield. So I was confident I would not have any issues with coverage.

Until today. I received a letter from the insurance company saying that the “request for full admission is denied as not medically necessary”. WHAT!?!? Nice to tell me after the fact.

And it stated that it “may help your doctor to know that we reviewed the request for full admission using the MCG guideline called Stroke Ischemic (ORG:M-83)”

I did look this up. Lo and behold, the MCG does state that “A diagnosis of acute ischemic stroke no longer necessarily indicates a need for inpatient care”.

My dx was exactly named: acute ischemic stroke on my discharge papers.

I immediately called my insurance and they just said “We don’t have any claims from this event yet, so we can’t comment either way”

Call the utilization review company and request a retro- pre certification. Explain that you were admitted to the ER and did not have time to pre-certify.
Have your doctor submit an appeal explaining exactly why you were in and if it was less than 24 hours then he just needs to change the procedure codes to match Observation rather than Inpatient. It will wind up paid but the provider needs to correct their billing. The claims analyst won’t be able to help you until they have the claim (bill) from the hospital."

 

[Forevermarypoppins]

The hospital wants to get paid. They will probably re-code the bill and resubmit. You can call them and alert them to the issue, if it makes you feel better.

I really do hate US health insurance.

As FORMER hospital coder, simply changing the code does not happen very often, The wriiten diagnosis by the physician as principal diagnosis can not be changed AFTER the fact.
Changes occur only when a mistake has been made. Sometimes adding a code can change results but again, the coder can NOT change what the DR has documented.