Question about an Emergency Room Bill?

[minkydog]

Interesting...the toe is painful and has green pus. While not life-threatening, certainly needs some evaluation. Feet get infected very easily and can result in some serious complications. There was obvious infection--what would be the point of waiting until there is a red streak running up the leg? More infection?

I woke up with fever & chest pain last year while we were on vacation. I had been coughing for a few days and now my chest felt like it was on fire. I was wheezing and short of breath, but we were up in Gatlinburg, 5hrs from home. I'm a nurse and I knew I wasn't dying, so I called my insurance co to ask about finding a local urgent care or ED. although there was an urgent care a few blocks away, they insurance co agent could not guarantee coverage. She suggested I go to the ED a few miles away where she felt sure I would be covered. I went and was diagnosed with asthmatic bronchitis and pleurisy.

Certainly this could have been treated in Urgent Care. I wasn't dying and I knew that. Had I been at home, I would have gone to the doctors office. But I was away from home and did not know the area. I felt more comfortable going to the ED for treatment in that situation. I'm sure the OP feels the same way. OP, you did the right thing. It's very easy for people to armchair quarterback, but you were there and had to make a decision. I would appeal this decision to the very top, if I were you.

 

[lesroi]

Interesting...the toe is painful and has green pus. While not life-threatening, certainly needs some evaluation. Feet get infected very easily and can result in some serious complications. There was obvious infection--what would be the point of waiting until there is a red streak running up the leg? More infection?

I woke up with fever & chest pain last year while we were on vacation. I had been coughing for a few days and now my chest felt like it was on fire. I was wheezing and short of breath, but we were up in Gatlinburg, 5hrs from home. I'm a nurse and I knew I wasn't dying, so I called my insurance co to ask about finding a local urgent care or ED. although there was an urgent care a few blocks away, they insurance co agent could not guarantee coverage. She suggested I go to the ED a few miles away where she felt sure I would be covered. I went and was diagnosed with asthmatic bronchitis and pleurisy.

Certainly this could have been treated in Urgent Care. I wasn't dying and I knew that. Had I been at home, I would have gone to the doctors office. But I was away from home and did not know the area. I felt more comfortable going to the ED for treatment in that situation. I'm sure the OP feels the same way. OP, you did the right thing. It's very easy for people to armchair quarterback, but you were there and had to make a decision. I would appeal this decision to the very top, if I were you.

Difficulty breathing = life threatening emergency. As a Nurse, I am sure you are smart enough to realize that. Infected toe does not = emergency. But don't take my word, take the hospital's that has already treated it and coded it and the insurance company that rightly denied coverage as an emergent incident.

I am not sure where you (and the OP) are seeing that ANYONE said they should have waited. In fact, they should have gone to Urgent Care earlier, as I and others have said. This is precisely the sort of thing that clogs up ED's needlessly!

I am not "armchair quarterbacking", I am explaining to the OP why her ED visit was denied payment by her insurance company. The FACT remains that it was NOT an emergent visit. The OP herself agreed with this assessment!

Telling the OP that she "did the right thing" by ignoring the infection until it got to such a state as to require urgent care is just the sort of advice that is messing up the US healthcare system. These types of things do not belong in the ED. Emergencies do!

Have you ever worked in an ED?

Tracy

 

[Lisa loves Pooh]

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.

I agree--there are many things that are bad and "urgent" care is needed....but it doesn't make them emergencies.

I had a UTI when in college. But didn't know it. My insurance states in the policy didn't cover ER visits for UTI's. Well I had woken up in the middle of the night in excruciating pain and a lot of blood in the urine. I had no idea what it was. When the ER told me UTI--I got upset b/c of the insurance. I was told by the ER staff that I did the correct thing--b/c it was a really really really bad UTI. (i couldn't even give them a sample and they had to get it the hard way ).

I don't know what they did for coding--but my insurance paid it all in full and it was never questioned.

(I had a PPO and the plan I had--I didn't have any co-pays! I loved it for the short time I was blessed to have it).

 

[Lisa loves Pooh]

Interesting...the toe is painful and has green pus. While not life-threatening, certainly needs some evaluation. Feet get infected very easily and can result in some serious complications. There was obvious infection--what would be the point of waiting until there is a red streak running up the leg? More infection?

I woke up with fever & chest pain last year while we were on vacation. I had been coughing for a few days and now my chest felt like it was on fire. I was wheezing and short of breath, but we were up in Gatlinburg, 5hrs from home. I'm a nurse and I knew I wasn't dying, so I called my insurance co to ask about finding a local urgent care or ED. although there was an urgent care a few blocks away, they insurance co agent could not guarantee coverage. She suggested I go to the ED a few miles away where she felt sure I would be covered. I went and was diagnosed with asthmatic bronchitis and pleurisy.

Certainly this could have been treated in Urgent Care. I wasn't dying and I knew that. Had I been at home, I would have gone to the doctors office. But I was away from home and did not know the area. I felt more comfortable going to the ED for treatment in that situation. I'm sure the OP feels the same way. OP, you did the right thing. It's very easy for people to armchair quarterback, but you were there and had to make a decision. I would appeal this decision to the very top, if I were you.

Urgent care centers are listed in the phone book. They often have really big ads in the physicians section.

It isn't armchair quarterbacking---since noone said..."oh well, you should have waited until you got home." It should have been seen...but it wasn't an emergency. Now if the toe was ready to fall off.....that would be more of an emergency.

An infected toe is not the same as chest pains and not being able to breath.

 

[Cool-Beans]

Insurance companies are doing this more and more, because Emergency treatment is supposed to be stuff that is life/death, or broken bones...stuff like that.

Stuff like ingrown toenails is probably better handled by a call to the doctor. If he deems it an emergency, he'll direct you to the ER, in which case the insurance will usually pay. If you are out-of-state, your insurance company can usually find you a doctor or clinic.

For future reference, it might be a good idea to make a couple calls before heading to the ER.

A friend of mine that works in the ER said one of the doctors there explains it this way, "If you can stop at McDonald's drive through for a coke on your way to the hospital, it isn't an emergency."

 

[It's A Happy Day]

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.

As far as the unpaid bill, call the hospitals billing dept., explain the situation and ask them if it is possible to check/recode and resubmit the invoice. Believe me, they want to clear it up as much as you do. It really could have been denied to them because they did not indicate it was an out of state occurance. I know that in the medical billing that I do (home health) many times an invoice can be coded incorrectly because there are soooo many different types of insurance and it may very well have been an error there. Any correspondence with anyone regarding the claim make sure you document - with the hospital get names, extensions, etc. With the insurance co. make sure to get claim #'s, reference #'s, names as well and document when, time, results. Many insurance co. will only let you dispute claims for so long - some 90 days, some more or less. If you have documentation it will help back up your claim. Also, Check your basic coverage information from your employer to see what services are indeed covered. I am covered with a co-pay ($50) for ER visits when not admitted, you may be able to argue that point. It is not up to the insurance co. to determine what is or is not an emergency, that is up to the physician!

For future reference, as I am sure you are realizing now anyway, unless absolute emergency try to call the PCP 1st and have them refer you as to course of action or your insurance co. 800 # to refer you to the closest facility. Out of state in that circumstance I probably would have done the same thing...I am unfamiliar with the area, I would drive to a hospital, not look around for an urgent care center. You can also call a local hospitals ER and ask for a triage nurse and briefly explain to them your problem...they may be able to advise you to steps to take at home/at a hotel before going to the ER. I have done this before as well to avoid sitting in an ER for something I could have tried at home 1st.

Good Luck

 

[Lisa loves Pooh]

A friend of mine that works in the ER said one of the doctors there explains it this way, "If you can stop at McDonald's drive through for a coke on your way to the hospital, it isn't an emergency."

That is a good way to think of that!

 

[Luv'sTink]

You can just soak out a ingrown toe nail? It does not need to be cut out so the tissue will heal? Will an infection as the OP described really go away just by soaking?

 

[Lisa loves Pooh]

You can just soak out a ingrown toe nail? It does not need to be cut out so the tissue will heal? Will an infection as the OP described really go away just by soaking?

I don't know how bad that infection was (I'll have to reread)....

But I have had ingrown with a pus factory toe nails and could soak them and treat them and survive. I think I was taken to the doctor once and that is what I was told to do.

I also used peroxide and meds like neosporin to help heal the toe.

What I was told to do when I realize the toenail is heading down the road of being ingrown--you can soak it...and then kind of pry it up (I use a metal nail file) and then stuff some cotton under it to keep it out of the skin--then it grows...and once long enough, it can't get ingrown.

 

[barkley]

i'm wondering if the issue with the insurance company is'nt so much that it was'nt an emergency as that it was'nt a life threatening condition. i live in california (where the op lived when the event took place) and if we travel out of state the only medical care whatsoever that my insurance carrier will cover is life threatening. for that purpose any time we travel and will not be in california or within close proximity to the california border we have to buy travel insurance (if i'm near the border i can go to any e/r or urgent care center in california at my discretion since i'm more than 50 miles from my primary medical group).

 

[Luv'sTink]

I don't know how bad that infection was (I'll have to reread)....

But I have had ingrown with a pus factory toe nails and could soak them and treat them and survive. I think I was taken to the doctor once and that is what I was told to do.

I also used peroxide and meds like neosporin to help heal the toe.

Thanks! I thought they had to be cut out to stop them from doing more damage.

ETA: I dont get them, my Mom does and she cuts the top of the nail and rips them out before they become infected and that is painful. So I thought I would ask.....I dont want to seem like a toe nail dork!

 

[Cool-Beans]

Sometimes ingrown nails have to be cut out.

 

[Lisa loves Pooh]

Thanks! I thought they had to be cut out to stop them from doing more damage.

Just read the OP--my toe didn't turn green..it was painful enough from what was going on already and so I could take care of it on my own as I had been instructed.

 

[twinklebug]

I had a visit to the ER that I had to fight with BCBS over many years back. In retrospect it didn't seem like an emergency as I survived and went home the same day, but when it happens it's hard to sit there and say "OK, let me get a referral first"

BTW - after the rejection I wrote a lengthy letter explaining the circumstances & the visit was deemed to be covered

 

[yeartolate]

Does your insurance have some sort of advice nurse?

I have had several recent policies that outside of a true life or death emergency, you had to call the advice nurse. She takes you through a truckload of questions , but at the end you have a for sure payment for your emergency visit.

 

[lesroi]

I dont want to seem like a toe nail dork!

Um, yeah... Tag Fairy??? Are you still awake???



Tracy

 

[jaimee1024]

I find this really sad. I've been to the emergency room for an ear infection before and it was covered. It was after midnight and the pain had become unbearable so I drove myself to the ER. And as for the green toe and the puss...that's nothing to play around with. I am recovering from a serious staff infection that started out with a couple of pimples on my stomach. One of them became abcessed. I went to urgent care. Twice. And after five days with no improvement I finally went to the ER where they told me that all the antibiotics in the world wouldn't have made a difference. The abcess had to be lanced and drained to get the infection out. If I had waited much longer the infection could have gotten into my blood or other internal organs. Staff infections can be fatal. Urgent care gave me antibiotics (two different oral and one shot) and sent me on my way. So, I don't blame you at all for taking him to the ER. I would do the same thing. Geesh...I know people who go to the ER for the flu. I've never heard of someone being denied for a "non emergency". I'm sorry that happened to you.

 

[dreamcometrue]

I would call the hospital you took your DS to and ask them to recode and resubmit. They will get their money regardless, whether it's from you or your insurance company and some hospitals are willing to work with you, since they don't really care WHERE it comes from, as long as they get it! Maybe they can review your case!

I agree with others, you probably should have gone to Urgent Care first. Most hospitals have both an ER and Urgent Care unit. I am surprised the ER didn't direct you to Urgent Care. They do that here, if you come in with something that is not truly an emergency!

 

[Cool-Beans]

I find this really sad. I've been to the emergency room for an ear infection before and it was covered. It was after midnight and the pain had become unbearable so I drove myself to the ER. And as for the green toe and the puss...that's nothing to play around with. I am recovering from a serious staff infection that started out with a couple of pimples on my stomach. One of them became abcessed. I went to urgent care. Twice. And after five days with no improvement I finally went to the ER where they told me that all the antibiotics in the world wouldn't have made a difference. The abcess had to be lanced and drained to get the infection out. If I had waited much longer the infection could have gotten into my blood or other internal organs. Staff infections can be fatal. Urgent care gave me antibiotics (two different oral and one shot) and sent me on my way. So, I don't blame you at all for taking him to the ER. I would do the same thing. Geesh...I know people who go to the ER for the flu. I've never heard of someone being denied for a "non emergency". I'm sorry that happened to you.

I'm honestly curious, and not trying to slam you. We hear so many stories about people in the ER.

If you went for 5 days with no improvement, why didn't you call your doctor? Why wait and then go to the ER?

Doctors and nurses have lots of theories about this, and I'd like to hear it from the other end.

 

[tspann]

Do you have a managed care plan? The Balanced Budget Amendment of 1997 (BBA) requires that managed care organizations adopt the Prudent Layperson’s Definition of emergency care.

Prudent Layperson Definition
Emergency Care - An “emergency medical condition” is a medical condition manifesting itself by acute symptoms of sufficient severity (including
severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of
immediate medical attention to result in:
(1) Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy;
(2) Serious impairment to bodily functions; or (3) Serious dysfunction of any bodily organ or part.

If the appeal to the insurance doesn't work file a complaint with the California Department of Insurance. You wouldn't believe how fast insurance companies correct claims when they receive a letter from the DOI.

FYI - This is exactly what I do for a living - help people make sure their insurance plans pay as they should and help them when they don't, as in your case. If you would like more help I would be glad to help you just send me a PM (no cost of course).