Hugs needed. ETA Question in post 1 UPDATE Post 1

[gatashcar]

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Edited May 7, 2017 by gatashcar

[SquirrellyMama]

We also have BCBS PPO, and on the back of our card it says "There are no out of network benefits (except in the case of medical emergencies)"

 

I would think this would be covered since it was a medical emergency.

 

Kelly

[Katy]

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?

 

I'm sorry, I should have given more detailed information earlier.  You call the insurance company.  You ask for a supervisor.  When you get one, you use the words, "Life threatening emergency," "Lawyer," and "Insurance commissioner."  Such as, "This was a life threatening emergency.  My daughter was unconscious and was taken to the closest hospital in a coma. This should be covered at the in-network rate or I will be calling my lawyer and filing a complaint with the state insurance commissioner today."

 

That will ensure you get the most experienced person (possibly even a department head) at the insurance company to handle it for you.  Then, compare the hospital bill to the insurance statement.  Typically even when a insurance company negotiates for in-network rates, the hospital will still bill it as out of network, which is fraud.  DO NOT PAY more than the in-network amount that your insurance company says you/she owes.

 

I worked as a nurse for a couple insurance companies.  They hire nurses for complicated claims such as your DD's.  Whatever you do, don't back down and don't pay the higher rate.  Even if you have to call a dozen times and talk to many people.

[Lawana]

Just a quick clarification. Dd was taken by ambulance, and while conscious, was way too ill to be making any reasonable decisions at all.

[zoobie]

Just a quick clarification. Dd was taken by ambulance, and while conscious, was way too ill to be making any reasonable decisions at all.

The patient often doesn't have any choice about where the ambulance goes, even if she had been lucid. Although this is unnecessary stress when you don't need it, it's good grounds for appeal. Can't get much more emergent than transported by ambulance. :grouphug:

[sarasue7272]

symptoms of ketoacidosis include confusion, blurred vision, difficulty breathing. So:

"This was a life threatening emergency. My daughter was suffering from ketoacidosis, therefore she did not have the capacity or the time to research where to have an ambulance take her, and was taken to the closest hospital. This should be covered at the in-network rate or I will be calling my lawyer and filing a complaint with the state insurance commissioner today."

I would go ahead and contact your state insurance commissioner and see what they advise, also.

[Lawana]

Bumped for update in OP

[Seasider]

Wow that's a great update!

[Ali in OR]

Yay! A win for the good guys. Thanks for posting the update--I love a happy ending.

[Alessandra]

Glad it was resolved!

 

We had a similar, but less dire situation, also BCBS. Surgeon took no insurance at all, but plan covered all his fees because it was an emergency, life-threatening situation.

 

When I researched ACA rules, it did appear that there were exceptions to the new rule -- some grandfathered plans. The actual rules were a bit complicated, but I thought worth a mention.