Hugs needed. ETA Question in post 1 UPDATE Post 1

[Lawana]

Did you know that when your dd is in the ER several states away with diabetic ketoacidosis, a potentially life-threatening condition, that instead of talking to the doctors and nurses about her clinical condition, you actually should be on the phone with the insurance company finding out that the hospital was out of network, and then arranging transfer to a different in network hospital?

 

Amount paid by insurance-- $4k

Amount she owes-- $35k

 

A little background. We live in a town with one hospital system. We have BCBS PPO which has a contract with local hospital and the vast majority of doctors in the area. We have not, in 2 decades, had to worry about which providers were in-network. So when dd moved to a large city fairly recently, in-network and out-of-network providers were not on anyone's radar. It certainly never entered either my or my husband's mind when she was going to the ER to worry about the insurance. Even when I flew there to be with her, it didn't cross my mind.

 

Of course we realize the mistake now. But what an incredibly expensive mistake that turned out to be.

 

I realize some of you may have suggestions about what to do. Please feel free to share, but I may not engage about them because I am still so shocked.

 

Last but not least, dd is fine now. She was in the ICU for a day and a half, then in a regular room for a couple more days. She returned to work the following week.

 

*********

ETA For those who have gotten the insurance to pay at in-network rates, do you then have to negotiate with the hospital to accept the copay based on those rates, versus the billed amount? How has that worked? In your experience, has the hospital been willing to accept that?

 

UPDATE: As of 8/19, the insurance has paid $35k of the $36k billed by the hospital! (The remaining amounts stated above are doctor bills) Thank you so much to the posters who stated that insurance was required to pay in-network rates because of ACA. That turned out to be the magic phrase when talking to BCBS.

 

After some back and forth to get the right documentation and BCBS's attempt to negotiate a reduced settlement with the hospital, which the hospital refused, the bill was paid as per our plan.

 

Now we can get to work on the doctors' bills.

 

I am so grateful to those in this community who freely share their knowledge and experience!

Edited August 20, 2016 by Lawana

[regentrude]

Hugs. That absolutely sucks. No advice; hope there is something that can be done.

But I am glad your DD is fine.

[Guest]

Ugh! I am so sorry about your DD, but I'm glad she is better!

 

Appeal the decision.  Out-of-networks are automatically denied, but IIRC, if you appeal and clearly lay out the facts that there was no in-network hospital within a reasonable distance, then there's a good chance it could be covered.  Of course, please take this with a grain of salt because it's been a while since I dealt with this.

[OneStepAtATime]

Huge hugs!!! And no, you should not have been having to worry about insurance when your daughter's life was in jeopardy. Grrrr. And more hugs.

[SemiSweet]

:grouphug: That is just awful :(

Edited June 28, 2016 by SemiSweet

[momof4inco]

We've gotten the DKA hospital bill before (though not quite that much). We're still paying it off from our daughter's diagnosis almost 2 years ago. I'm sorry you are having to deal with it, but I'm very glad your daughter is okay.

 

In an emergency situation like that... Can you appeal and get them to pay more? If she had waited to go to another hospital, bad things could have happened.

[Lawana]

Ugh! I am so sorry about your DD, but I'm glad she is better!

 

Appeal the decision. Out-of-networks are automatically denied, but IIRC, if you appeal and clearly lay out the facts that there was no in-network hospital within a reasonable distance, then there's a good chance it could be covered. Of course, please take this with a grain of salt because it's been a while since I dealt with this.

In the city she is in there are plenty of in-network hospitals. It is our area that has only one hospital. If any of us had thought to enquire, she could have been taken to one that would have been covered at a much much much higher rate.

[Arcadia]

:grouphug: :grouphug: :grouphug:

We appeal a decade ago also with Blue Cross PPO and with the hospital. The hospital was more generous.

Edited June 28, 2016 by Arcadia

[Lawana]

We've gotten the DKA hospital bill before (though not quite that much). We're still paying it off from our daughter's diagnosis almost 2 years ago. I'm sorry you are having to deal with it, but I'm very glad your daughter is okay.

 

In an emergency situation like that... Can you appeal and get them to pay more? If she had waited to go to another hospital, bad things could have happened.

I don't know. They sent it through twice at our request because it seemed completely insane. What would we base an appeal on? We didn't think to check?

[kwickimom]

Appeal!!! When I had BCBS they did that to me and I called and got the charges down to the in-network price. I basically told them either do that or I'm never going to pay. The hospital I went to was actually in network but the doctor and lab and basically everything else were not. 

 

Horrible. Sorry you are dealing with that. 

[momof4inco]

http://obamacarefacts.com/questions/is-out-of-network-emergcy-care-covered/

 

I found this. I wonder if it applies to your daughter's situation...

[freesia]

I find it appalling that emergency care is not automatically considered "in network". I have nothing else nice to say about our entire system.

[momof4inco]

And this...

 

https://www.healthcare.gov/using-marketplace-coverage/getting-emergency-care/

 

From reading this and that other link I posted, it doesn't sound like they are legally allowed to do this under ACA. Your daughter's condition was an emergency, as evidenced by the fact that she was in the ICU!

 

On one of those pages, it says you may have to appeal to get the coverage (which is completely ridiculous).

Edited June 28, 2016 by momof4inco

[creekland]

:grouphug:  Wish I could do more, but that totally sucks.  I wish we had a better health care system.  (payment wise)  :grouphug:

[J-rap]

I am so sorry.  I worry about this too, with all the traveling our kids do.  One dd is working in another state over the summer (college student), and ended up in the ER twice already!  Our insurance does have in small print that although it doesn't cover out-of-network costs until it's over something like $25,000 or $35,000, it DOES cover out-of-state ER visits.  Is there any chance yours covers ER visits?  I've also heard that some insurance plans will extend their coverage to college students that are out-of-state.   I'd certainly appeal to your insurance company...it won't hurt!   If the insurance company refuses to do anything, maybe you could appeal to the hospital and see if you could work out some kind of reduction with them.

[gardenmom5]

hugs.

momof4 gave some good info on appealing.

[Lawana]

http://obamacarefacts.com/questions/is-out-of-network-emergcy-care-covered/

 

I found this. I wonder if it applies to your daughter's situation...

Very interesting! I will look into it. Thanks!

[Seasider]

Wow. Vent away. We also have BCBS and seriously, it's so widely accepted that it wouldn't occur to me that any metropolitan hospital wouldn't take it. Can you file the claim on your own?

[Lawana]

Wow. Vent away. We also have BCBS and seriously, it's so widely accepted that it wouldn't occur to me that any metropolitan hospital wouldn't take it. Can you file the claim on your own?

The hospital accepts it, but does not have a PPO contract with BCBS. The hospital filed the claim with BCBS, but BCBS paid on it at the out-of-network rate, which if I understand correctly is limited to 70% of the Medicare reimbursement rate, even though she is not on Medicare of course. All the laboratory fees ($20k, labs drawn every two hours around the clock) were completely disallowed, because they were considered part of the facility charge. Eh? That doesn't even make sense to me. And ALL of the ER charges were disallowed because she was admitted and they were rolled into the facilities charge. So all the insurance paid on was ICU, regular room and some drugs. All the rest was disallowed. That is why it seemed insane to me.

[Seasider]

The hospital accepts it, but does not have a PPO contract with BCBS. The hospital filed the claim with BCBS, but BCBS paid on it at the out-of-network rate, which if I understand correctly is limited to 70% of the Medicare reimbursement rate, even though she is not on Medicare of course. All the laboratory fees ($20k, labs drawn every two hours around the clock) were completely disallowed, because they were considered part of the facility charge. Eh? That doesn't even make sense to me. And ALL of the ER charges were disallowed because she was admitted and they were rolled into the facilities charge. So all the insurance paid on was ICU, regular room and some drugs. All the rest was disallowed. That is why it seemed insane to me.

Wow. That's insane. I hope you can find a way to make an appeal work. If you are truly talking about tens of thousands of dollars here, perhaps it would be worth your time to consult with someone who is an expert at handling such things? I'm not sure if that would be an attorney or other professional.

[Garga]

Please appeal. And why didn't the hospital confirm all that? Every time someone goes in the hospital, they call the insurance company for the benefits. Why didn't they alert you? Jerks.

 

Appeal, appeal, appeal. I don't even know what you can base it on, but it's crummy that they won't work with you. From their point of view, you are supposed to know your benefits. You are supposed to call and find out. You did make an honest, in good-faith mistake, but they might not care. See if you can talk to someone in the finance office at the hospital for wording to appeal.

 

You simply must try to appeal. And be sure to appeal in writing at least twice. (If you haven't appealed yet in writing, then it doesn't count. A phone call doesn't count.)

[Lawana]

They may have told dd, but she was so ill, and alone, that it would have not meant a thing to her.

[Garga]

Well, do appeal twice in writing. Eons ago I worked at a health insurance company and the loved to deny appeals...the first time. The second time they'd take you a little more seriously.

[frogger]

I am so sorry. I'm glad your daughter is now ok. It can't hurt to attempt an appeal.

[freesia]

They may have told dd, but she was so ill, and alone, that it would have not meant a thing to her.

They probably didn't. I don't know how they expect you to know that you are suppose to check (especially at an in network hospital). Our first 7 years with kids was in Canada and when we moved back I had no idea that I needed to check with everyone who came in the room to see my daughter. I assumed that THEY would check if our insurance covered them, I guess??? Anyway, it still makes no sense to me the way you get blindsided like that. Our responsibility was nothing like yours in terms of money, but it was several thousand that we didn't expect. Again, I'm so sorry.

[Lawana]

I had no idea about the risks involved with using an out-of-network provider. When I looked at the max out of pocket amount for out of network, I assumed that meant that is all we would have to pay before the insurance paid 100%. The missing part is that coverage is linked to Medicare reimbursement rates, and anything beyond that is 100% the responsibility of the patient. No limits. That is the insanity.

[lllll]

:grouphug:  :grouphug:

[Carol in Cal.]

Ugh ugh ugh

I hate this stuff.

[Miss Tick]

Talk to the hospital, too. It is possible to get them to reduce their costs sometimes. I hate all that stuff. We're all supposed to be "smart consumers" but nobody can tell you the actual price of anything.

[redsquirrel]

16 years ago I had the same thing happen. I went into labor at 32 weeks and ds1 was born. While in labor, I drove in the middle of the night to the nearest big hospital. It is an hour away. They had the closest level 1 NICU. My local hospital didn't have a NICU. My midwife didn't want him born in a hospital without immediate NICU services and a 24 hour neonatal team.

 

My insurance at the time, Aetna, refused to pay for his NICU care because it was an out of network hospital. Even though it was the nearest hospital with the ability to care for him, they would not pay.  I don't know what they expected us to do if he had been born in the local hospital, we would have been sent by ambulance to the same hospital.  The hospital told me not to pay any $$ (and we had a HUUUUGE bill). In the end they sued Aetna and won. We still had to pay hundred and hundreds, but not tens of thousands.  It took about 3 years to get it all straightened out. The billing dept at the hospital where I stayed was quite helpful. I think because they knew there was no way any one person could pay the bill for a birth and then weeks and weeks of level 1 NICU care. It was either make the insurance company honor it's obligation or get paid nothing.

 

 

Anyway, if you have an questions about why health care costs so much, start with things like this. The hospital had to sue an insurance company. I am sure the lawyers got their cut, on both sides.

[zoobie]

You said she was *taken*, so I would appeal on that. Don't say anything about how you/she didn't know. She wasn't able to make that call and was taken to the nearest hospital. Ambulance? Unconscious or barely conscious? The more incompetent she was to make a decision, the better for the appeal. Your state insurance ombudsman's office may be able to help, or possibly even google around for appeal process letters for BCBS.

[JonesinIndiana]

I'm so sorry this is happening to you and your family.

 

You said your daughter was alone at the ER? When I was In the hospital w gall bladder issues the hospital wouldn't give me any pain meds until I had signed all the paperwork. The nurse said I had to be clear headed without any medications that could cloud my thinking, or something like that. Was your daughter given any medications that could have contributed to her not understanding the provider/ insurance info? (Like being at the ER isn't reason enough!🙄.) You might look into appealing the charges if they gave her medications that could cause confusion. I had gone to the ER of another hospital for my gallbladder and they gave me instructions to follow up w my MD after doing basically nothing but give me an IV of pain meds. They were out of network but I didn't know that. They were a few blocks from my house. When they sent the bill I sent a letter stating they released me with blood pressure of 165/106 with the clerk getting my info told me that the BP reading couldn't be right because that would be for really sick people! I had surgery that night for my gallbladder! I never got another bill from them.

 

YMMV my surgery was in 1997. 🤔 My advice is appeal. Good luck.

[kwg]

:grouphug:  I am so sorry  :grouphug:  

[Katy]

In truly life threatening situations such as hers, there are often exceptions to that rule.  Ask for a manager at the insurance company (not the first person who answers).  Ask them the process to get out of network treatment covered for life-threatening emergencies.  There should be something.  Sometimes the insurance company has a waiver and covers at the in-network rate.  If not, the hospital should have procedures in place to negotiate the bill.

[Spryte]

I find it appalling that emergency care is not automatically considered "in network". I have nothing else nice to say about our entire system.

I agree. All ER care should be in network.

 

That's just horrible, OP.

 

I'm glad your DD is okay.

Edited June 29, 2016 by Spryte

[momto3innc]

We had this happen with emergency surgery on our middle son (when he was a year old). My husband just honestly would not back down, called and called, asked for superiors, wrote to them, and finally (after a lot of pushing back on his part) they gave us in network as it was an emergency and you know...his life was at risk. Silly us not to ask about the network as he's being held down for an IV. Seriously just the most ridiculous thing. For us the hospital was in network but the surgeon and anesthetiologist were not (which is a whole other level of crazy to be aware of).

[gardenmom5]

I spoke with dh - he's an agent.

was this an actual bill - or a statement of charges but not an actual bill?  there can be lots of negotiating back and forth between the hospital and insurance company.

if this is a bill, and your insurance company refuses to pay - contact your state insurance commissioner.   they are supposed to cover out of network emergency medical expenses.

[justasque]

We have had good luck appealing BCBS a couple of times in the past.  We did it in writing, and it may have taken a bit of a fight, but in the end they paid up.  Good luck, OP.

[TechWife]

And this...

 

https://www.healthcare.gov/using-marketplace-coverage/getting-emergency-care/

 

From reading this and that other link I posted, it doesn't sound like they are legally allowed to do this under ACA. Your daughter's condition was an emergency, as evidenced by the fact that she was in the ICU!

 

On one of those pages, it says you may have to appeal to get the coverage (which is completely ridiculous).

 

When ds was in the hospital, the PICU nurse told me that everything they do in the PICU is considered "emergent care" and PICU patients aren't considered to be eligible to transfer hospitals unless they are going to a hospital with a higher level of care than the current hospital can provide. Of course, I don't know how up to date her information was, and Obamacare actually went into effect during ds' hospitalization, so that could have changed things. Who knows? Perhaps that might give you a basis for an appeal, though - that she was receiving care and wasn't  stable enough for a transfer? Of course, that won't get you around the fact that the insurance company wasn't contacted. Generally, out of network stays have to be approved ASAP. All of what the hospital is willing to say for the insurance company must be based on the facts in evidence in her medical chart - evidence should be tied to her specific test results, RN and MD notes as well as the acceptable standard of care for her diagnosis. 

 

You really need to talk to someone at the hospital to get them to write a formal appeal. Sending a claim through twice won't be sufficient in this case, they must provide written documentation to back up their claim that they should be paid for the services. 

 

If all else fails and the hospital has to be paid, I think you have some room for negotiating. At some point, a person should have looked at her billing information and they should have picked up on the fact that they weren't a participating hospital with that plan. At that point, contact should have been made with the insurance company to see if they would approve and pay for the stay. It is common practice for the hospital to make that contact on behalf of the patient. Legally, the insurance policy is a contract between the insurance company and the insured, though, and in the end, the patient is responsible. It stinks in situations like that. At the very least, ask them to discount the bill for her, that is common practice as well for uninsured patients as well. Is it possible she would qualify for Medicaid in the state where she lives? 

Edited June 29, 2016 by TechWife

[TechWife]

dp 

 

Edited June 29, 2016 by TechWife

[mamiof5]

I am so glad your dd is ok! Sorry about the network ordeal, it's just ridiculous. I hope you can appeal and she's not stuck with a huge medical bill. Years ago we had an emergency situation and had to appeal, got denied...appealed again and got denied, but dr ended dropping the remaining balance. It was minimum compared to your cost, but there's always hope something will work out.

[Ali in OR]

And this is why we need single-payer health care in this country (my personal opinion anyway). You shouldn't have to go through this. Keep fighting.

[happi duck]

(hugs)

[basketcase]

The hospital wants to get paid. There's always room for negotiation directly with them. And I'm so sorry about this! Majorly frustrating.

[kewb]

Appeal. If she went to the er for an emergency then it should be covered.

 

Insurance companies are the pits when it comes to these things.

 

I am glad your dd is okay now.

[Guest]

My insurance company considers ER visits to be in-network.

[regentrude]

nm

Edited June 29, 2016 by regentrude

[Sandragood1]

Appeal multiple times based on your dd's condition - it was a life threatening emergency.

 

If they won't budge, then I'd get a lawyer. $35k is worth a lawyer.

[ashfern]

What a pain! Glad your DD is ok. Looks like you got a lot of good advice here. Good luck!!

[Dynamite5]

Did you know that when your dd is in the ER several states away with diabetic ketoacidosis, a potentially life-threatening condition, that instead of talking to the doctors and nurses about her clinical condition, you actually should be on the phone with the insurance company finding out that the hospital was out of network, and then arranging transfer to a different in network hospital?

 

Amount paid by insurance-- $4k

Amount she owes-- $35k

 

A little background. We live in a town with one hospital system. We have BCBS PPO which has a contract with local hospital and the vast majority of doctors in the area. We have not, in 2 decades, had to worry about which providers were in-network. So when dd moved to a large city fairly recently, in-network and out-of-network providers were not on anyone's radar. It certainly never entered either my or my husband's mind when she was going to the ER to worry about the insurance. Even when I flew there to be with her, it didn't cross my mind.

 

Of course we realize the mistake now. But what an incredibly expensive mistake that turned out to be.

 

I realize some of you may have suggestions about what to do. Please feel free to share, but I may not engage about them because I am still so shocked.

 

Last but not least, dd is fine now. She was in the ICU for a day and a half, then in a regular room for a couple more days. She returned to work the following week.

Don't apologize for not knowing all of this--they make it confusing on purpose!

 

First of all, DON'T PAY ANYTHING until you are happy with the results and agree on the charges.

 

Secondly, KEEP COPIOUS NOTES!  Write down the phone number you call, the person you speak with and the date and time.  Tell the person you need their full name for documentation.  

 

Keep appealing and appealing and appealing.

 

Hopefully, you'll be able to get it all straightened out.  I am happy to hear your daughter is better.  How scary!