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

[Dan Murphy]

Another thought. A patient can be kept in a hospital, even overnight, for 'observation', and technically not be 'admitted'. The person filling out the coding at the hospital end could mistakenly code it as an admission, when technically, it was not.

 

[lanejudy]

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.

THIS! I have spent years dealing with sometimes very complicated medical stuff in my family. While I do keep an eye on the claims, I never worry until the bill actually arrives. So often, the doctor resubmits with additional documentation which then gets approved. If necessary there are appeals processes in place, but I've only had to do with that once or twice in the past 20 or so years. The bill almost always gets worked out by the hospital and insurance.

 

[mom2rtk]

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.

My dad has dealt with it for years. Wasn't diagnosed until he had a blood clot (post retirement). I have been checked and (thankfully) don't have it.

 

[DisneyHardin]

As others have said, wait until you get a bill. Recently I got an EOB from a blood test that I had run that apparently was run by an out of network lab. The EOB said I was going to owe $1500 for this test. I was so stressed out about it and mad that my doctors office didn't tell me the lab was out of network. When I finally did get the bill from the lab, it was for less than $200.

 

[VandVsmama]

MCG = managed care guidelines.

It also refers to the name of an application that health insurance companies use by their Utilization Management/Care Management departments to ensure that healthcare providers are following industry standards of care…and those standards of care usually follow Medicare/CMS guidelines.

The hospital provider can also submit a grievance/appeal for your situation. There’s usually a very structured process that insurance companies have to follow on this, and they get audited on that process regularly.

 

[tvguy]

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.

I'd love to put you in a room with my neighbor, who worked for insurance companies reviewing codes hospitals used on billing. Lots of honest mistakes, but one hospital billed for a hysterectomy ........for a man! And when the billing was rejected, they actually appealed!

 

[mom2rtk]

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.

It wasn't discovered until 1994 (My dad was diagnosed in the late 90's). When I was finally aware and tested (because it runs in my family), I had been on BCPs for many years and had 3 babies. My doctor ran the test but was quite sure I would be negative because my system had been adequately "tested".

 

[KPeterso]

Make the hospital aware. They will appeal on your behalf. Also, discuss with your employer HR department too. They will have a contact at the insurance company and can make some calls on your behalf as well. The employer is paying BC/BS the premiums and may be unhappy to hear that claims are denying for a hospital admission.

 

[china mom]

I have received letter from the insurance company stating that coverage was denied and then never heard from anyone about it again. I assume the medical provider either appealed, refiled or ate the cost. Don't worry until you get billed.

 

[Forevermarypoppins]

I'd love to put you in a room with my neighbor, who worked for insurance companies reviewing codes hospitals used on billing. Lots of honest mistakes, but one hospital billed for a hysterectomy ........for a man! And when the billing was rejected, they actually appealed!

Coder mistake, code gets changed.

 

[tvguy]

Coder mistake, code gets changed.

Not in this case. Hospital appealed.

 

[Forevermarypoppins]

Not in this case. Hospital appealed.

Then there is "more to it" .

 

[tvguy]

Then there is "more to it" .

Yes, which is in my original post.

 

[DisneyTeacher]

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.

I’m glad you’re on the road to recovery and you’re doing well. I also have Factor V Leiden. I also learned the hard way after a massive blood clot. As a result of a second clot my doctors looked a little harder and found I have a couple of other clotting disorders as well.

If your insurance denies the claim call the hospital, they should be able to help you.

 

[BrianL]

I really don't know about the insurance issues, but I'm so glad that you're okay. That's the most important thing! I'm sure it'll get all straightened out.

 

[snowwite]

Another thought. A patient can be kept in a hospital, even overnight, for 'observation', and technically not be 'admitted'. The person filling out the coding at the hospital end could mistakenly code it as an admission, when technically, it was not.

That is what I believe happene.

 

[snowwite]

Coder mistake, code gets changed.

I think i replied to the wrong one

 

[PollyannaMom]

I was alone. I called an ambulance and they got me to hospital quite fast.

“A diagnosis of acute ischemic stroke no longer necessarily indicates a need for inpatient care”.

These are the keys here - it might not necessarily require an overnight stay, but it very likely does require someone to keep an eye on you for a bit of time. The doctor's call not to send you home alone was completely reasonable!

I agree that the hospital might handle it themselves, but if you do get a bill, fill out the forms for an appeal. - To that end, keep every piece of paper they sent you home with.

I expect it would also be good to write down any doctor's and nurse's names that you remember taking care of you, in case the insurance has questions for them. (The hospital can check records, but it might be faster if you already know.)

Glad you are OK!

 

[Mackenzie Click-Mickelson]

Also keep in mind the surprise medical bills act, while it's primarily aimed at out of network charges for in network facilities it's also about giving you the patient the good faith estimate of charges so that you are better informed.

One would think if a guideline says it's no longer necessary for inpatient care that the hospital is duty bound to notify you of this. You'd also want to know if by the guidelines of the insurance company and the hospital if your stay qualifies as inpatient care with or without full admission as I could see them saying you were under observation (if they leaned towards that in the end) but then still considered it inpatient care. Not all hospitals use the same definition. Some may consider inpatient by the very fact that you received overnight care.

I'd wait to get the actual bill to go over the full details of what it is though but keep all the documentation. Some things may also come crossed in the mail too.