Insurance Woes

[Melrosgirl]

My dd hurt her wrist back a few weeks ago. She never cried. Just said it hurt. Took her to the pediatrician (I didn't think it was serious). Doc said she thought it was broken. OOPS. She told us to go to the hospital to get it x-rayed. We go to hospital. Hospital is the right hospital to go to per our insurance.

Well turns out the doctors who x-rayed and set her broken wrist do not take our insurance. They work at the hospital which takes our insurance, but these doctors don't take our insurance. This was the ONLY doctor the hospital could find on call at the time. (Saturday afternoon)

So they are billing us and the insurance only paid them a very small out of network percentage.

Am I crazy to think that every person who touches me at the hospital needs to be asked "do you take my insurance?" I figured if they work for the hospital which takes my insurance, they must take my insurance too. UGH. Guess not.

Apparently though, had I just taken my dd to the E.R. instead of going through my pediatrician, this would all be covered 100% (less my $100 e.r. copay). Now I could be looking at almost $1000 out of pocket b/c I didn't take her to the e.r. and let the out of network doctor touch my dd.

We're trying to talk to the doc's office now. Seeing if they can re-code this correctly as an emergency as all we did was walk into the hospital, get it x-rayed and they sent the only doctor they could find on duty. My insurance company says if the doc's office will re-code it as an emergency, they will pay all of it (less deductible). Grrrrrrr.

 

[vivilasvegas]

Unless you were actually seen in the ER, it would be illegal for them to code it as an ER visit. There are separate codes and you probably received an office/outpatient code.

Did you make an appointment with this doctor? Within a hospital there can be quite a few medical groups, you should always check what insurance they take.

 

[Melrosgirl]

No appt. DD walked in with my doctor's order saying to get an x-ray, then they said it was broken. Then they sent the only doctor in they could find to set it (soft cast - took 5 minutes). This was AFTER they made us fill out paperwork which asked for insurance info.

 

[j's m]

I also had this problem with our local hospital when I had DS. The hospital was in network, so I assumed all costs would be in network. Our pedi was in network, too, but since he was not there for the delivery (as most are not) the hospital has on staff neonatologists who are NOT in network. But same as you, no one told us up front, nor is anyone else available, you must use them. So we had the same out of network costs. I feel that if they are seeing you in an in network hospital, you don't have a choice and all the doctors should be in network, too. Good luck.

 

[chrissyk]

That is really terrible and confusing. You went to an in-network hospital, and yet the Dr. was still billed as out-of-network...awful! I would fight this one like crazy, because what logical person would even think that that could happen

 

[Poohgirl]

This happened to me to except it was for the birth of my second son! My Dr. was out so I had a step in. Then the insurance company says "sorry that Dr. isn't in our network" b.s. whatever. So, I wrote a letter to the insurance company basically telling them that I used their hospital in good faith and that I was doing what I was supposed to and in turn they should in good faith cover the step in Dr. They did end up covering everything as if it would have been in-network. If you need to, write a letter to the ins. company and explain the situation and that you were following their procedure. Good luck!

 

[Texan Mouseketeer]

When my sister had her baby, she was put in the NICU for 23 days and almost didn't make it. The NICU doctors are on a constant rotation - well, only one of those doctors that saw my neice were on my sister's insurance. So all that time the money was just adding up. Frustrating part was that she had no choice in the matter, what was she going to do, just have her daughter looked at on Mondays from the 7-7 shift? Her bill came out to the in the six figures. She's grateful her daughter is alive, but still paying on that bill three years later and may be doing so for the next 20...that just doesn't seem fair to me. And yes, she did try fighting it with every group and organization she could go to.

 

[chrissyk]

When my sister had her baby, she was put in the NICU for 23 days and almost didn't make it. The NICU doctors are on a constant rotation - well, only one of those doctors that saw my neice were on my sister's insurance. So all that time the money was just adding up. Frustrating part was that she had no choice in the matter, what was she going to do, just have her daughter looked at on Mondays from the 7-7 shift? Her bill came out to the in the six figures. She's grateful her daughter is alive, but still paying on that bill three years later and may be doing so for the next 20...that just doesn't seem fair to me. And yes, she did try fighting it with every group and organization she could go to.

That is HORRIBLE! How is that even possible Your sister had this baby at an in-network hospital, and this still happened? Are these all situations of HMO's that aren't widely accepted or something? Also, I thought that pregnancy/childbirth/newborn care was all covered under "Global Authorization" from your health insurer. Maybe this excludes Dr.'s that aren't on the plan even if they work at the in-network hospital, though Can your sister get a lawyer to help her fight this? It seems surreal that you could think that you were following the rules of the health plan and then find out that you're STILL not covered

I wonder if this would still happen with high-deductable health insurance an an HSA...I'm convinced that that's the way that healthcare is going in the next 10 years, and I'm not convinced that that's a bad thing. Maybe these horrid HMOs will go by the the wayside in this case.

 

[vivilasvegas]

The thing is, the hospital stay was probably covered, but then the doctors also charge for each inpatient visit. They are called E/M codes. It does stink, but that's how it is.

My job is to audit those inpatient notes and make sure the doctor is actually documenting for the code he is charging you for. Say he bills a 99223 (expensive), I will audit his note and see if he has documented enough to reach that level. Often they don't, but sadly, most hospitals still don't have this auditing system.

 

[RitaZ.]

That is really terrible and confusing. You went to an in-network hospital, and yet the Dr. was still billed as out-of-network...awful! I would fight this one like crazy, because what logical person would even think that that could happen

The hospital that they sent the OP's DD to is an in-network facility. However, the doctor that treated her DD is obviously not a participating physician for their medical plan. I know it doesn't seem fair, I mean if your insurance company sends you to a hospital that's in-network, then one would think their doctors accept your insurance as well. Apparently that's not the case, they are totally independent when it comes to insurance billing.

I learned this when DS had go to the emergency room for a broken finger. The doctor that treated him did not accept our insurance. I learned this when the billl came in, we had to pay it. By the way, we have a PPO. It used to be a great plan, until Humana took over (they are horrible). A lot of doctors around here won't have anything to do with their insurance, I can't say that I blame them. Fortunately, we are done with them as of Jan. 1.

Maybe someone that works in medical insurance can explain it better.

 

[Kirk]

This has happened to me before. I appealled my insurance decision as beyond my control and they finally caved. Worth a try

 

[chrissyk]

The thing is, the hospital stay was probably covered, but then the doctors also charge for each inpatient visit. They are called E/M codes. It does stink, but that's how it is.

My job is to audit those inpatient notes and make sure the doctor is actually documenting for the code he is charging you for. Say he bills a 99223 (expensive), I will audit his note and see if he has documented enough to reach that level. Often they don't, but sadly, most hospitals still don't have this auditing system.

So what is the average person supposed to do Does a person need to ask each physician that comes to see them in the hospital if they are on their insurance plan That seems illogical and impractical, especially if someone is critically injured. It seems surreal to me that you can have health insurance, go to an in-network hospital, and still leave with a huge bill of non-covered charges

Would a person actually be better off with high-deductable health insurance that caps the out-of-pocket max at 5K or 10K a year in that case? Would that insurance then have to cover all of the "out-of-network" visits, when an HMO wouldn't I'm seriously thinking of looking into high-deductable insurance for us even though we have an inexpensive PPO through DH's work. I just don't think that the PPO is good coverage, and stories like the ones in this thread just confirm that to me.

 

[Sleepy]

When my dad has blood drawn, he has to tell them which lab to send it to.

 

[chris1gill]

This is totally illogical!!! Although it did happen to me once, when I took DD in for an X Ray... the Radiologist apparently was NOT in our insurance network even though the hospital was... eventually they paid the bill though... I mean, he's the guy that read's your X Rays... it's not like you have any say over the matter....

But I can see it now...

You're in the hospital, your dear loved one <insert name> is in critical condition.... Doctor comes over....

Excuse me sir, I have XYZ insurance, can you tell me before you treat my loved one, are you in the network?

Your loved one expires as he figures that information out...

It's as illogical as the entire insurance industry.... well, that explains it doesn't it....

 

[Mackey Mouse]

Something similar to this happened to me..

I went for an endoscopy.....the doctor doing the procedure took my insurance, the facility it was done at took my insurance, but the anesthesiologist they used was not in my insurance.

It was a battle, but there is some law on the books in MA covering the fact that I had no choice on who was on duty to do the anesthesia....actually the facility where the procedure was done told me and gave me the exact words to use with my insurance company...wish I could remember more, but I think quoted the law by number to my insurance company. They paid the bill.

Worth looking into though, really did you have a choice on who they used for your daughter....probably not...

 

[Texan Mouseketeer]

It is a school district's insurance for my sister, so not obscure or anything. There is a clause that if there is no one in that field on your plan then they have to cover an out of network doctor. But since one NICU doctor was on the plan that loophole was a no go. It was explained to her that most NICU doctors work so hard (And I agree with that!) that they don't want to have to cut their costs to what HMO's determine should be paid for certain treatments. So many of them don't get on any of those plans. I think she did consult a lawyer, but if I remember correctly he must not have thought she had a strong case because that route was not pursued. Very frustrating...

 

[vivilasvegas]

It is a school district's insurance for my sister, so not obscure or anything. There is a clause that if there is no one in that field on your plan then they have to cover an out of network doctor. But since one NICU doctor was on the plan that loophole was a no go. It was explained to her that most NICU doctors work so hard (And I agree with that!) that they don't want to have to cut their costs to what HMO's determine should be paid for certain treatments. So many of them don't get on any of those plans. I think she did consult a lawyer, but if I remember correctly he must not have thought she had a strong case because that route was not pursued. Very frustrating...

They can do that for procedures, but they still have to follow Medicare/HCFA guidelines for documentation. A hospital can be sued for millions when doctors overcode (charge patients more). It has happened and cost the hospital over $40 million.

There isn't much a patient can do, but if you think you were charged too much for a visit, you can call your insurance or hospital and ask for them to have someone in the coding compliance department recode your visit. I've done it quite a few times and saved the patient money.

A hospital won't ever have one insurance. It depends which physician group your doctor belongs to. Unfortunately, you'll have to ask each new doctor which group he's in and find out which insurance they accept.

I work at a hospital and there are doctor's there not covered by my insurance!!

 

[DWDreams]

This happened to me once. I fell down stairs coming out of a friends house while holding my daughter, a baby at the time, and purposely took the fall on my knees since I didn't want to fall forward and injure her. Four concrete steps and pavement at the bottom really hurts! Needless to say, I went to the ER for xrays and both knees were so swollen the xrays were useless and there was no ortho on call to examine me or the film. The ER told me to return to the ER the following day to be seen by an ortho. Everything turned out okay, but a few months later I was notified that the ortho exam from the following day wouldn't be covered because the doctor wasnt in my plan. Well, that was completely unacceptable to me -- who can choose what doctor will be available when you're in the ER? So I didn't let it go and after much discussion back and forth it was acknowledged that the ortho had billed his services as an office visit examination rather than an ER examination. Once that was realized, the insurance had the ortho rebill it correctly and it was paid without further issue.

It might not be the same, but might be worth checking.

 

[chrissyk]

It is a school district's insurance for my sister, so not obscure or anything. There is a clause that if there is no one in that field on your plan then they have to cover an out of network doctor. But since one NICU doctor was on the plan that loophole was a no go. It was explained to her that most NICU doctors work so hard (And I agree with that!) that they don't want to have to cut their costs to what HMO's determine should be paid for certain treatments. So many of them don't get on any of those plans. I think she did consult a lawyer, but if I remember correctly he must not have thought she had a strong case because that route was not pursued. Very frustrating...

Well, a NICU is a 24/7 place, and the one Dr. on her plan couldn't obviously work 24/7. I would have pursued it with the lawyer since technically there would have been no Dr. in that field on her plan for 16 hours a day. What a sickening situation. Did she ever contact the state insurance commissioner? I'd keep pursuing it, even years later. That's a LOT of money

 

[chrissyk]

A hospital won't ever have one insurance. It depends which physician group your doctor belongs to. Unfortunately, you'll have to ask each new doctor which group he's in and find out which insurance they accept.

I work at a hospital and there are doctor's there not covered by my insurance!!

OMG, how impractical is that??? You are in the hospital because you're sick or delivering a baby or injured in an accident, and you're supposed to ask each new Dr. that you see which group he's in and if he accepts your insurance Talk about ridiculous! What if you're unconcious and can't ask?!

Also, doesn't this situation just encourage overuse of ERs? If an illness or injury will be covered 100% with just the ER copay but might not be covered with the PCP referral to the in-network hospital, people are going to choose to go the ER route. That is normally the MORE expensive method for treatment, so this type of situation is actually encouraging overuse/abuse of the ER IMHO.