Question about an Emergency Room Bill?

[poohandwendy]

I don't think it was anyone's intention to insult the OP, let me say that first. That is the inherent problem with messge boards: people want an opinion but are often insulted if the opinion does not agree with theirs. They then cannot help but defend their actions or position.

The OP has repeatedly agreed that she should have gone to urgent care. She agreed with that, and will do it in the future. Kudos to her for having the guts to even come on here and ask! Unfortunately, the toe problem is in the past. She asked why the bill wasn't covered and many people correctly explained why.

Again, YOUR situation WAS markedly different. I am not sure why, as a practicing RN, you are not seeing that a BREATHING problem and an infected toe in NO WAY compare. I am not sure why you would encourage people to appeal an insurance company decison that seems very much in the right.

My DH worked Charge and Triage in a Peds ED in a very MAJOR metropolitan city (for many many years.) He has guaranteed me that if this pair showed up in his ED, they would have enjoyed an 8 hour wait while more emergent patients were seen. That's just a fact. And it is because of the perception that "it hurts, and my Doctor's office is closed, so it must be an emergency" mentality. Now wouldn't this time have been better spent at an urgent care facility with a 15-minute wait for treatment? Or even time better spent soaking the toe back at the hotel?

Sorry to be so harsh, but it's a FACT that an infected toenail is NOT AN EMERGENCY and that is why the insurance didn't pay. Appealing the insurance company's decision is the only recourse (albeit wrong.) If they pay it is a shame and it promotes the usage of the ED as a "clinic" rather than the EMERGENCY department it is MEANT to be.

This is one of the fundamental reasons why the healthcare system in America is so messed up. People do not see the Doctor on a regular basis and then let things get to such a state that they can't take it anymore so deem it an "emergency." We have to learn, as a whole, to be PROACTIVE with our healthcare. I am certain it is a scary situation as a parent when you are faced with an infection like that, but that is why you take PROACTIVE measures beforehand. Many on this thread with the same type of problem have suggested home treatment regimens. Ingrown nails are a recurrent and chronic problem, not an ACUTE problem. They require constant treatment and care to avoid.

Sorry again OP that you had to learn this financial lesson, but the insurance company was right to deny the claim, especially if they state that they will only pay for real emergencies treated in the ED. It puts you in a tough bind with your ex as well. He should really be the one fighting this as it is HIS insurer. I would certainly pass the information on to the hospital that HE is responsible for 50% of the bill! You should not have to pay it in the entirety. I would also tell the hospital to contact the insured, your ex, for any further billing or insurance questions. As someone who is not even on the policy, they should not be contacting you until they have completed every bit of fight with the insurer. (Coincidentally, they don't try very hard to get the insurance company to change their mind. They know they can't bill you unless the insurance has been billed. Once they bill the insurance and the insurance says "no", it's open season on you. They really don't care who pays as long as they get their money.)

to you as this is not a fun situation! As someone who was raised by a single Mom, I can completely sympathize with your position.

Tracy

Very well said!

 

[jaimee1024]

Not the person that told the story, but here's my $0.02...she went to the Urgent Care twice. I presume she saw licenced doctors there. Two times they gave her antibiotics and told her she'd be fine. At that point, a non-medical person starts to feel like an idiot. They don't want to become an "Elaine" at that point, having people they consider to be experts (doctors) thinking there's nothing wrong with her except she's a pain in the ***. The doc said she'd be fine, so she waits, thinking the antibiotics will start to work, may take a few days. Heck, one of the urgent care docs may have told her it'd take a few days. At day 5, she's realized it probably should have worked, and now she's really scared.

I think some docs and nurses forget that there are a lot of laypeople out there, without any medical knowledge or experience in medical matters.

I didn't mean to make this about me or my choice to go to the ER. I only shared my story because of the infection issue. My point was that anything involving infection and puss etc...could possibly be quite serious.

As for why I chose ER...someone else explained it well (thank you by the way). On Wednesday they gave me a shot of antibiotics and TWO oral antibiotics and sent me on my way telling me it should clear up in a few days. I gave it two full days and by Saturday it had not improved at all and I got scared. My family Dr.isn't in on Satudays, so I called his AS and guess what they told me? Go to the ER. And it's a good thing I did because they told me that the antibiotics were doing me no good. I HATE going to the hospital...trust me...

As for the OP...I'm a little baffled by the hostility on here. I think she did what any Mom would do when her child was in pain. Not all towns have Urgent Cares on every corner (or at all) and even if they do, they might not accept whatever insurance you have. IMO the fact that she was out of town and her son was in pain made it an emergency for her. I don't understand the need to make her feel bad for her decision.
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[TeresaNJ]

Sorry DisneyMama, but it was not an emergency. No matter which way you look at it, an infected toe does not qualify as an emergent situation unless you were now septic from the infection. Your son could have gone to a physician in Texas, an urgent care center, any other type of outpatient clinic, but not an ER. I know it stinks, but that's the way it is.

 

[poohandwendy]

As for the OP...I'm a little baffled by the hostility on here. I think she did what any Mom would do when her child was in pain. Not all towns have Urgent Cares on every corner (or at all) and even if they do, they might not accept whatever insurance you have. IMO the fact that she was out of town and her son was in pain made it an emergency for her. I don't understand the need to make her feel bad for her decision.

I don't think anyone is trying to make her feel bad for her decision, just trying to explain why it wasn't covered by the insurance. Because it doesn't qualify as an emergency per their policy.

 

[twinklebug]

I worked with a medical insurance company for a few years and what baffles me is why they create so many rules for what they will/won't cover and HOW to go about getting treatment for the issues, and then don't draw out a clear rules sheet to be placed at the top of your information packet with a "READ this FIRST" title.

Instead they make it into a research project... you have to dig into your 1" thick books - when they're supplied, and often you winde up calling just to make sure you're following their rules before making that appointment or running off to the ER. Wouldn't it make a lot of sense just to put "In an emergency" info on the back of the ID cards? But they won't do it because they keep changing their own rules.

It would be interesting to know how many cases have wound up in court just because coverage was denied when simple, better communications could have prevented the issue. And how many of those cases were awarded to the plaintif.

 

[TeresaNJ]

She was actually ADMITTED and they refused to pay? That's nuts!

Unfortunately, just because a doctor admits you to the hospital doesn't mean it meets the insurance companies "acute illness" criteria. Any physician can admit a patient to a hospital that he/she has priveledges at. Even Medicare is denying hospital stays now if the patient's illness doesn't meet the guidelines. Believe me, I dealt with this every day for three years as a Case Manager. Imagine me having to go into a patient's room who is dying and placed on hospice care, and telling the family that they must move their loved one elsewhere, as a hospital is for "acutely" ill patients. Now you know why I'm not a Case Manager anymore.

If the doctor refused to discharge the patient to another level of care (home with home care, rehab, etc), and it was a Medicare/Medicaid patient, then I had to issue a notice of non-payment. Mind you, the doc still gets paid, but the hospital doesn't, and legally the hospital cannot bill Medicaid for non-acute days in the hospital, so the patient gets billed by the hospital.

The same goes for Managed Care. If the Managed Care company denies days, the doc still gets paid and the hospital doesn't. So who do you think is paying for all this?

 

[Maleficent13]

It would be interesting to know how many cases have wound up in court just because coverage was denied when simple, better communications could have prevented the issue. And how many of those cases were awarded to the plaintif.

I'm going to guess not many make it to court, because most people just end up paying it rather than go through the aggravation. Insurance companies know this will happen 9 times out of 10, and therefore have no inclination to make anything user friendly.

 

[taximomfor4]

Unfortunately, just because a doctor admits you to the hospital doesn't mean it meets the insurance companies "acute illness" criteria. Any physician can admit a patient to a hospital that he/she has priveledges at.

The difference is, the inpatient stay was covered as an acute illness. It was the ER visit that was not covered, even though her tachycardia was too severe for the pediatrician to keep us at his office, and too severe to send her HOME out of the ER (after 10 hours in the ER, they admitted her to a floor and kept treating and monitoring her).

Beth

 

[justhat]

Another alternative to urgent care (which is where I would have gone also) would be to call the insurance company and ask them for the names of physicians in the area you're visiting for your problem. Even with the insurance being your ex-husband's, they can still give you the name of a dr in your network.

To the poster who talked about her college being in a small town, with no urgent care or university health clinic open past 5pm or on weekends, the ER is still only a place for true emergencies. If it's a regular illness or minor injury and the dr is closed, then it can wait till the next day or Monday. If it's life threatening then it's ER worthy at any time of the day, not just when the clinics are closed. If it's not life threatening, and something you would see a regular dr for, then that same thought applies when the regular dr is closed-it can wait.

Oh, and about the recording at the dr's office that says "if you think this is an emergency...," ours say "If this is a life threatening emergency, hang up and dial 911." Both the ped and my ob word it like that, which I think is a great thing cause it should weed out some of the complaints that are not true emergencies.

 

[Lisa loves Pooh]

She was actually ADMITTED and they refused to pay? That's nuts!

That is nuts. Our PCP--only sees patients that work for hubby's company--and we all have the same insurance. It is United Health Care. They have a stance of not denying something the doctor felt was necessary. In our case--since they only see patients with our specific plan...they know how it all works. Not everyone is blessed with that and it totally sucks to get denied.

But the fact the child was admitted to the hospital....that is just crazy to deny coverage. That is a case of the insurance company playing doctor.

 

[jaimee1024]

I guess some people may be willing to suffer (or worse, watch their children suffer) until their Dr's office is open the next day, but I can tell you that without a doubt I would have my DD at the ER in a heart beat if she was in pain that I wasn't able to relieve or if she had something going on that I couldn't figure out. If you think for one second I would trust some insurance company rep or "advice nurse"to tell me whether my description of a condition was "life threatening or not" then there is a ski lodge in Hades I'd like to sell you. I am not a medical professional nor is that insurance rep. And nurses are not Doctors. There are thousands of illnesses, diseases and injuries that are not necessarily life threatening, but most certainly need immediate attention. I am not one of those Moms that calls the Dr (or runs to the ER) every time my DD is sick. In fact, she hasn't even been to the Dr. since her last check up a little over a year ago. We have gotten through a couple of fevers and colds. I am fortunate she hasn't had anything worse than that. I'm not sure who decided that imminent death was the only thing that qualified as an emergency, but I sure am grateful that my Dr's and insurance company don't see it that way.

 

[justhat]

I guess some people may be willing to suffer (or worse, watch their children suffer) until their Dr's office is open the next day, but I can tell you that without a doubt I would have my DD at the ER in a heart beat if she was in pain that I wasn't able to relieve or if she had something going on that I couldn't figure out. If you think for one second I would trust some insurance company rep or "advice nurse"to tell me whether my description of a condition was "life threatening or not" then there is a ski lodge in Hades I'd like to sell you. I am not a medical professional nor is that insurance rep. And nurses are not Doctors. There are thousands of illnesses, diseases and injuries that are not necessarily life threatening, but most certainly need immediate attention. I am not one of those Moms that calls the Dr (or runs to the ER) every time my DD is sick. In fact, she hasn't even been to the Dr. since her last check up a little over a year ago. We have gotten through a couple of fevers and colds. I am fortunate she hasn't had anything worse than that. I'm not sure who decided that imminent death was the only thing that qualified as an emergency, but I sure am grateful that my Dr's and insurance company don't see it that way.

Odds are something like an ingown toenail, ear infection, etc. doesn't just suddenly go from no pain to excruciating pain that is unbearable. Most likely there was increasing pain over a period of time. Instead of waiting till it gets to that unbearable point, go to a dr sooner and get treated. Cases that need ER treatment are deemed "Sudden and Serious." Ingrown toenails are not sudden and serious. No one is telling anyone to suffer, however-people are pointing out that the appropriate course of action is to see a medical professional before the pain is too severe. That way no one suffers, ERs aren't clogged up, and no one has to pay an exorbitant, and unnecessary, ER bill.