Question about an Emergency Room Bill?

[DisnyMama]

The bottom line is the insurance company is not paying the bill for my DS ER visit last July while we were in Plano. Texas. This maybe TMI for some but it is relevant to the problem. DS had a nasty ingrown toenail that was turning his toe green and oozing puss..yeah gross, and very painful. He would not be able to see his doctor in California where we lived at the time for another 2 weeks so I had no choice but to take hime to the ER. They removed it and gave him antibiotics because of the infection. Ok, hospital does there coding I assume and sends the bill to the insurance company. They won't pay stating that it wasn't considered an EMERGENCY!! I exchange words with them telling them that it could not have waited 2 more weeks and it was infected because they did give him an antibiotic. It seems that maybe it is a problem with the way it was coded by the hospital. Does anyone have any ideas or suggestions as to what could be the problem or how I should handle this situation. I would really appreciate any advice.

 

[lesroi]

A lot of policies are set up like this now. If they deem it not a true emergency, they will not pay for emergency treatment. It stinks, but it is happening mainly due to people going to the ED for things that are not life-threatening.

I agree your DH may not have been able to wait 2 weeks, but you could likely have gone to an Urgent Care center for way less than half the price. (Hence the denial from your insurance company.)

Having worked in the medical field (and my DH having been a Charge Nurse in the ED for many years) I can tell you this type of thing happens a lot. It's sadly just one of the many reasons that the wait in the Emergency Department is so long. So many people are there that don't belong in the ED.

Hope you are able to get it worked out to your satisfaction. Everyone should check their policies. A lot of companies will just not pay the ED fee, not deny the claim alltogether, but you never know unless you read your policy carefully.

Good luck!

Tracy

 

[justaquestion]

The bottom line is the insurance company is not paying the bill for my DS ER visit last July while we were in Plano. Texas. This maybe TMI for some but it is relevant to the problem. DS had a nasty ingrown toenail that was turning his toe green and oozing puss..yeah gross, and very painful. He would not be able to see his doctor in California where we lived at the time for another 2 weeks so I had no choice but to take hime to the ER. They removed it and gave him antibiotics because of the infection. Ok, hospital does there coding I assume and sends the bill to the insurance company. They won't pay stating that it wasn't considered an EMERGENCY!! I exchange words with them telling them that it could not have waited 2 more weeks and it was infected because they did give him an antibiotic. It seems that maybe it is a problem with the way it was coded by the hospital. Does anyone have any ideas or suggestions as to what could be the problem or how I should handle this situation. I would really appreciate any advice.

They probably used a 99283- which is an emergency room evaluation code. That is the codes they have to use since the care took place in the emergency room setting. You can ask for that code to be checked by an auditor (which I is what I do). They will review the doctor's documentation and based on that, level the visit. Your visit could be leveled lower if documentation did not meet criteria for chosen code (which would also be lower in price), but I don't think that will help in your case. Your problem is with the er visit itself.

You can ask what the diagnosis code was. If it wasn't specific enough, (say just ingrown toenail, but they did not code the infection) they can add another diagnosis and resubmit the claim.

 

[Hannathy]

As a former ER nurse have to agree with above poster about real emergencies. Did you call your insurance or home DR. before going? sometimes if they give you the ok they will pay or tell you where to go- I know too late this time but for next time.

 

[Lisa loves Pooh]

I can understand the POV of the insurance company. If it were me and since i'd be out of network anyway, I would have used an urgent care clinic instead and then filed.

We did that with DD when she was little and woke up Christmas Eve morning looking like Rocky Balboa with her eye all swelled up.

We still paid OOP entirely b/c of our out of network deductible--but it was cheaper than a possibly denied ER visit (though in that case--it probably would have been covered since she was a baby and it involved her eye. Turned out to be a reaction to a bug bite.)

You can probably call billing at the hospital--explain the situation and see if they can bill it under a different code.

I had lab work done for a covered emergency in VA....and it was denied repeatedly. the hospital was actually very very very excellent in pursuing the matter--pointed out the standard of care as well as whatever medical board mumbo jumbo that indicated it was a required and necessary thing. Well the insurance refused to pay and I wasn't going to pay. But they send us a very very NICE letter and explained the situation in detail as well as the justification of why it should have been covered but just wasn't being paid by insurance. They then gave us a discount so that the bill was not as big of a bite. It was like a little kid asking pretty please for dessert. We felt that they handled it well and due to their excellent handling of the manner, we didn't argue and paid it (it wasn't that much in relation to the rest of the bill that sent hubby to have a cow of his very own when it came to our co-pay).

 

[candicenicole19]

My dd (Then 3) broke her arm by falling off of the sofa and I took her to a quick care ER and our Insurance would not pay for it~ They said if a bone was not prutruding out then i should have waited to see her PCP and had him send her to someone to cast it! Funny thing is that I saved them a TON of money by going to quick care and not the hospital and by having my neices father cast my dd's arm free of cost! Kind of funny and now I am negging him to bill them for it! lol!

 

[DisnyMama]

Thanks for the advice.
I never even gave a thought to taking him to an urgent care clinic. That probably would have been a better thing to have done. I will contact the hospital and see what we can do regarding the coding of the visit and resubmitting the bill to the insurance company. However, ultimately I will end up paying some portion of the bill and have learned a very important lesson in regards to how things work with the insurance companies that I did not know before.

 

[golfgal]

An ingrown toenail is not an emergency. It could have been treated at home soaking it in warm soapy water or Epsom salts. It probably would have cleared up in a couple days and been fine. I know with our insurance Urgent Care is the same co-payment/coverage as a dr's visit so I always go there if I can't get into the dr. Never go to the ER unless it is truly something that can't wait. You probably also have a nurse hotline you can call and they probably would have told you to soak it in warm soapy water or Epsom salts and if it wasn't better in a couple days to give your regular dr a call back.

 

[tiggger1]

I beleive if it was green and had pus then it should be concidered an emergency. It could have caused a blood infection or worse... yes she probably could have gone to Urgent care but if her city is anything like mine, there is only 1 urgent care center and it is only opened till 5 pm. Heck my ped is open later than that!

 

[Caropooh]

Does your insurance company require a refferal? I went to Urgent care once and the claim was denied because i didn't have the refferal first. They were able to retro the refferal back, resubmit the claim and then it was paid. Might want to try that.

 

[golfgal]

Does your insurance company require a refferal? I went to Urgent care once and the claim was denied because i didn't have the refferal first. They were able to retro the refferal back, resubmit the claim and then it was paid. Might want to try that.

You need a referal for Urgent Care, YIKES? What's the point of urgent care then?

 

[golfgal]

I beleive if it was green and ***** then it should be concidered an emergency. It could have caused a blood infection or worse... yes she probably could have gone to Urgent care but if her city is anything like mine, there is only 1 urgent care center and it is only opened till 5 pm. Heck my ped is open later than that!

Sorry, not true at all. That is your body's normal reaction to an injury, which is basically what the ingrown toenail is. My DH got them all the time, I have had plenty of my own, many have gotten majorly infected, all have been cured with soaking. If she noticed red streaks coming out of the infection site, then you need to call your dr but for a regular infected toenail, no emergency trip is necessary.

 

[Caropooh]

You need a referal for Urgent Care, YIKES? What's the point of urgent care then?

I believe all we really have to do is call insurance and get authorization, so maybe referal wouldn't be the correct term! I'm not sure exactly because we never had to do it again.

 

[golfgal]

I believe all we really have to do is call insurance and get authorization, so maybe referal wouldn't be the correct term! I'm not sure exactly because we never had to do it again.

Even still, weird. We have Urgent cares that are in our network and they are the same as going to your regular dr they are just open after hours, usually 4-9 on weeknights and 9-4 weekends. It keeps people out of the ER for non-emergency things and keeps medical costs down. I am surprised they want you to call in even, that would discourage people from using it I would think. I have never heard of this I guess.

 

[DisnyMama]

As far as the ingrown toenail being an emergency, yes, it was! We had been driving from California to Texas and in our hotel for a couple days doing the soaking thing with epson salt and neosporin but it just got worse. We were looking for a home and dealing with a realtor and then driving back to CA. Just me and DS (15). His pediatrician in CA. has already removed an ingrown on the same toe a year and a half earlier. I told her when we got back what happened and she said we did the right thing and that due to infection (because it was pussing) it would not have been a good idea to have waited, in fact dangerous, to have waited another 2 weeks.

 

[LaraK]

I would recommend two things. First, contact the hospital and see if they can audit for accuracy and then appeal the decision. Make sure you ask that the account is held during this process so that it doesn't age and kick you into collections.

At the same time, I would submit a written appeal to your insurance company explaining that you were out of state, that the toe appeared to be infected and that this was something that was significantly concerning as you strongly suspected significant infection.

If that doesn't work, ask for the complaint department, patient advocate, patient representative or whatever they have at each place. All hospitals have a designated person that can help you negotiate the system. (I know, that's what I do for a living)

 

[golfgal]

As far as the ingrown toenail being an emergency, yes, it was! We had been driving from California to Texas and in our hotel for a couple days doing the soaking thing with epson salt and neosporin but it just got worse. We were looking for a home and dealing with a realtor and then driving back to CA. Just me and DS (15). His pediatrician in CA. has already removed an ingrown on the same toe a year and a half earlier. I told her when we got back what happened and she said we did the right thing and that due to infection (because it was pussing) it would not have been a good idea to have waited, in fact dangerous, to have waited another 2 weeks.

If your pediatrician thought it was 'emergency room' worthy, why couldn't they get you in that day? That just doesn't make sense. I am not saying it wasn't bad, just not an emergency. I have to side with the insurance company on this one.

 

[lesroi]

As far as the ingrown toenail being an emergency, yes, it was! We had been driving from California to Texas and in our hotel for a couple days doing the soaking thing with epson salt and neosporin but it just got worse. We were looking for a home and dealing with a realtor and then driving back to CA. Just me and DS (15). His pediatrician in CA. has already removed an ingrown on the same toe a year and a half earlier. I told her when we got back what happened and she said we did the right thing and that due to infection (because it was pussing) it would not have been a good idea to have waited, in fact dangerous, to have waited another 2 weeks.

No one here EVER suggested waiting 2 weeks. The fact that you did not take care of it sooner proves that it was not an emergent situation to begin with. The prudent decision would have been urgent care. Your Doc's inferrence that the ED was the proper decision is sad. That kind of thinking contributes to the overcrowding and the increase in medical costs we are all faced with today.

An ingrown, infected toenail is NOT a life-threatening emergency. The Emergency Department is for life-threatening emergencies, sorry.

Tracy

 

[Caropooh]

Even still, weird. We have Urgent cares that are in our network and they are the same as going to your regular dr they are just open after hours, usually 4-9 on weeknights and 9-4 weekends. It keeps people out of the ER for non-emergency things and keeps medical costs down. I am surprised they want you to call in even, that would discourage people from using it I would think. I have never heard of this I guess.

I thought it was odd too, but at least it got paid in the end. We have other insurance now!

 

[autumnbaby9]

If your pediatrician thought it was 'emergency room' worthy, why couldn't they get you in that day? That just doesn't make sense. I am not saying it wasn't bad, just not an emergency. I have to side with the insurance company on this one.

The OP was out of state. It would be a little hard to get to your Ped.