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Help me appeal unreasonable out-of-network charges
September 15, 2010 10:29 AM   Subscribe

How do I effectively deal with medical charges due to emergency surgery having been done by an out-of-network surgeon?

My husband fell ice skating in April and broke his hip. After he fell and couldn't walk, we called paramedics who loaded him in an ambulance and took him to the emergency room. At the emergency room, the admitting nurse came and evaluated him and took him to be x-rayed, at which point the orthopedic surgeon who was on-call in the emergency room came in and said my husband needed surgery as soon as we could get him anaesthetized. So we said ok.

Fast forward to now: everything has been in-network so far (emergency charges, ambulance, hospital stay, etc.): except the surgery itself (which they just billed in mid-August). The insurance company says the surgeon is out-of-network and so we are responsible for all charges over what they cover. So the ~$12,000 surgery charge* includes ~$6000 that we are responsible for.

Clearly, we want to appeal this, but I'm confused about process and potential resolutions. Some questions:
  1. Should we start by appealing to the hospital, or the insurance company?
  2. Is it reasonable to think the surgeon should have been in-network? Or covered at an in-network price because we didn't have time to arrange to fly to Seattle for the surgery? The insurance customer service rep said that "most orthopedic surgeons in Alaska are out-of-network".
  3. What does an insurance appeal look like? Do I say "here's what happened, here's why I think it sucks, and here's what I'd like to happen?" I gather it all has to happen by (paper) mail.
  4. Is it really fair that the hospital does emergency work on you and then comes back and says "oops, sorry, even though you have insurance you're SOL"? I suppose in this case we could have asked before the surgery, but supposing you're unconscious or something?
Further details: I'm in Fairbanks, AK. This all happened at the only hospital in 300 or so miles. The surgeon apparently retired from working in Wasilla, but Fairbanks was short on-call orthopedic surgeons and so he was working up here two-weeks-at-a time (and then going home for a month or something). But this is probably irrelevant, as it's Fairbanks Memorial Hospital Physicians Group doing the billing.

*We're being charged for two surgeries plus an "overage" charge because the insurance makes doctors give a discount if they're doing two surgeries at the same time, and we're being charged for the balance of the non-paid part---even though there was only one surgery done. But this part makes more sense how you would appeal it, although if folks had concrete things to tell me, I'd appreciate it.

Thanks for any advice you have: this is awfully complicated and anxiety producing.
posted by leahwrenn to Work & Money (16 answers total) 1 user marked this as a favorite
 
Document every call you make and every letter you send. Who you talked to, why, what they said, and their contact info. You could try directly appealing to the insurance company first, but if you need an advocate see if the hospital has a hospital social worker or a patient advocate/someone who handles insurance muddles. The hospital may also be able to "forgive" some of this balance. Good luck.
posted by ShadePlant at 10:34 AM on September 15, 2010


Don't bother talking to the hospital. They are a business and need to be paid regardless; they don't do surgeries for free just because someone else (the insurance company) did something odd. As a matter of practice, hospitals tend to be quite lenient about reducing balances owed by people (in cash) rather than those billed to insurance companies. If you approach the hospital with a statement of "unfortunately, I can't pay $6000 immediately due to my finances, can you help me with it?" rather than blaming them for doing their jobs, you'll have a better chance of them forgiving some of the balance.

Feel free to appeal since you have nothing to lose, but your story (except for the odd overage bit) sounds very clear cut - you bought insurance that did not cover what you did. There's nothing about "fairness" here - it's a business transaction between you and the hospital that you incorrectly thought would be covered by your insurance. Your incorrect assumption in no way changes how the hospital bills you and your insurance company.

I would suggest putting your effort into figuring out how to pay the bill rather than getting out of it. Also, consider supporting comprehensive health care reform in the United States.
posted by saeculorum at 10:46 AM on September 15, 2010


Read your policy or policy summary carefully, and/or have a talk with the HR people at the employer through which you've got the insurance. Your insurer is only on the hook here if the policy says they're on the hook. Some policies have special provisions for emergency situations where an in-network provider is unavailable. If your insurer is doing what they're contractually obligated to do then try appealing to the hospital.

Try not to frame these issues around what seems fair to you. Fairness really doesn't mean diddly squat here.
posted by jon1270 at 10:47 AM on September 15, 2010


I have the utmost sympathy for your situation. Facing a medical bill that high is horrible, when you thought you were insured. This isn't necessarily because of anything the insurer or physician is doing, but because you, like many people, have slipped through a crack in the current health care payment system.

There are two reasons you are responsible for a high amount. First is that the insurance provider is requiring you to pay higher coinsurance at an out-of-network rate. That is between you and the insurance company. The second is that the medical providers are billing you at a higher rate than they would if you were on an in-network plan. That is between you and the medical providers.

1. I think things are pretty cut-and-dried with the insurance company. The sorts of things you can appeal are things like denied procedures, which your physician claims are medically necessary and your insurance staff says are not. Someone is in-network or not and it's pretty clear this guy isn't. Unless there is some sort of exception in your policy for emergencies, I wouldn't waste your time by dealing with the insurance company.

For out-of-state medical care, my insurance pays an amount between the in-network and out-of-network rate. If your plan does not, and you have other options, you might consider a plan that does this or has some sort of national network.

2. No, it's not reasonable. You knew who was in-network when you signed up.

3. I wouldn't bother with this, although saeculorum is right when he says you have nothing to lose by trying, other than your time and some frustration.

4. None of this is fair because the U.S. health care system is inherently unfair. That doesn't mean that you have any sort of redress in the present system.

Here's what I would do. Find out what insurers are in-network for the physician group, and then how much the allowed amount for the procedure would be if you were insured by them. Then phone the physician group billing office and say that it is a financial hardship for you to pay the full amount right now, but that you would be able to pay the allowed amount from your insurance company, which coincidentally is close to what they would bill you if you were in-network. If you have that kind of cash, you could say that you could pay it today; otherwise ask for a payment plan. Ask to speak to a supervisor if this is declined. If still no, write a letter to someone higher up. Only after you have exhausted your other options, start bringing up that they are charging you an unreasonable amount much higher than they would someone insured in-network, and potentially ask a lawyer if this is grounds to get it reduced somehow. Good luck.
posted by grouse at 11:06 AM on September 15, 2010


2. No, it's not reasonable. You knew who was in-network when you signed up.

Here's the thing: we had done our due diligence. We knew that the emergency room and the hospital were in-network. We went to the emergency room, and used the surgeon who was on-call in the emergency room at the hospital. Saying that therefore, we should have asked every single health-care provider we encountered (the anaesthetist, the nurses, the ambulance, the admitting nurse) "no wait: are you in-network? are you in-network over here?) when we had already verified previously that the emergency room and hospital were in-network seems unreasonable.

That's why I'm having so much trouble understanding the situation: this guy was the on call surgeon in the hospital emergency room, which was supposed to be in-network (and indeed, the bills we received for the emergency room stuff was covered in-network. But where did the magic change-over happen?)

I understand that medical providers need to get paid, and I understand that at some point we will have to pay (probably), but this wasn't a case of elective surgery, and we didn't have a choice of where and when to go.
posted by leahwrenn at 11:14 AM on September 15, 2010 [1 favorite]


I have no solution, only commisseration. I've wound up with high cost copays thanks to emergency surgery where the *anesthesiologist* (didn't have a choice) was out of network. Everyone else, in network. My partner had a strange situation where the doctor's office and hospital location were in network, but the lab in that hospital is out of network. Like most people in the US, there are only a few options. It is difficult, if not impossible to accurately find out who is in network and who is out of network. We've been told one thing prior to appointments, only to find out that "oops" oh that is counted as out of network. I really wish these things could be spelled out more clearly. Generally, doctor's offices confirm that they accept insurance. I've found out belatedly that "accepted" does not always equal "in network". Your best bet will be to contact the hospital ask for assistance. Sometimes they will drop some of the charge, other times they will set up a payment plan. The US system really does suck :/
posted by Librarygeek at 11:22 AM on September 15, 2010


That is a fair point. I have been through the same thing, where I was told service would be provided by a particular institution that I knew was in-network, and then only when I was billed I found out that one particular department of that institution was not in-network.

I do think it is unreasonable, but that doesn't make it anyone else's problem in a legal sense. Mentioning this and that you feel you were a little misled might make you seem a little more sympathetic to the billing supervisor, but in the end, if they write off the higher charges it will probably be as "a courtesy" for financial hardship purposes rather than to avoid trouble. You might consider talking to your Congressman's office as well.
posted by grouse at 11:25 AM on September 15, 2010


If your insurance is through an employer, have you talked to your HR department?

I JUST just went to a seminar on our health insurance, and the one thing that was very clear was that there are a lot of ins and outs. E.g., it was mentioned that anesthesia would be charged as "out of network", and then readjusted to "in network" pricing.

It is just possible that you are being billed for non-emergency prices, and out-of-network fees are waived for emergencies, and they just need documentation.

Don't take your bill at face value; if you can have a specialist (like an HR health rep) evaluate it, you may find that you're liable for much less than you thought.
posted by endless_forms at 11:38 AM on September 15, 2010 [1 favorite]


Fairbanks is small enough that if this was off-hours in any way, he might very well have been the only guy available short of a Medevac to Anchorage or Seattle. I think that your best bet is to see what contingencies there are in your plan for real emergencies where an in-network surgeon is not available. Get that clear- hopefully there is some provision??- and then pursue this angle. If your husband truly required within-a-few-hours emergency surgery AND this guy was the only guy around who could do it AND there are provisions for that in your policy, you find some way to prove that to the insurance company and it might work out.
posted by charmedimsure at 11:45 AM on September 15, 2010


This happened to my husband, who had a severe broken wrist in a snowboarding accident. The hospital was in network, but the orthopedist who treated him sent the bill from his own practice. Our insurance carrier charged this as out of network. He had called three times, and was unsuccessful each time (they just kept telling him to have them resubmit the bill). When I called, I told them to check the PLACE OF SERVICE on the claim. Because the service was emergency and was provided at an in network location, the entire claim needed to be paid as such. And it was. Give it a try...
posted by smalls at 11:48 AM on September 15, 2010 [2 favorites]


^^^ Sorry, I should have clarified that we were calling our health insurance provider, not the orthopedist's practice.
posted by smalls at 11:49 AM on September 15, 2010


It doesn't sound like an in-network surgeon was available. I'm not sure about your policy, but many policies charge in-network rates when you don't have a choice of where you're going. Your husband needed emergency surgery. There were no other hospitals or surgeons available. I think that is a strong argument on your behalf. The surgery could not have been put off until you found an in-network person.

You might have to fight about this and you might have to make lots of calls and deal with incompetent people, but your reward would be saving thousands of dollars.

I know of two cases in point where people received out of network service at in-network prices when an in-network option was not available. In both cases, it took a few months to have everything resolved and there were lots of hoops to jump through, but in the end, both people were charged the in-network rate.
posted by parakeetdog at 12:55 PM on September 15, 2010 [1 favorite]


Have you explained the situation to the surgeon? After all, he wants to get paid! When my insurer refused to pay for more than ⅓ of my $15000 bill for surgery, I asked my surgeon what to do — with the implication that if there wasn't more money coming from the insurer, I didn't know how I would pay him — and it turned out that his office retains a lawyer specifically to appeal insurance denials. They took care of both a first- and second-level appeal, and finally the insurer covered ⅔.
posted by nicwolff at 2:48 PM on September 15, 2010 [1 favorite]


- Read your policy very carefully, looking for pertinent information. You don't mention the specific provisions of your policy in your question, but you imply that it should work a certain way. Probably you're right; if you have the specific sections and language it will help.

- Do call the hospital. Even if the charges are ultimately your responsibility (and don't come off as blaming them when you call), they may have experience dealing with this kind of thing and may be able to give you some helpful information. Try to talk to someone experienced; you're looking for lessons of experience.

- The Alaska Division of Insurance might have some guidance for you. If all else fails, there's a complaint mechanism.
posted by amtho at 3:39 PM on September 15, 2010


I appreciate all the advice upthread. It was very helpful in helping me figure out how to approach the problem.

I started by talking to Heather at the company that is responsible for
billing for the surgeon. After a month or so (no one ever calls back when they say they will) it was determined that the issue is that the surgeon works as a locum doctor for the hospital, and the hospital can't be bothered to contract their locum doctors with blue cross. And she says that's all she can do. I say, ok is there someone at the hospital I can talk to about this, and get a phone number for someone who turns out to be head of patient accounting (Tina).

Ok. Meanwhile, I submit an appeal in writing to the insurance company detailing the case. I receive a written response in about a week, in which they explain that in fact, they had paid out at the in network rate! The money we're on the hook for is the difference between the allowable in-network rate and the billed amount, which, since the surgeon was out of network, we are responsible for paying.

So I eventually talk to someone (Sandra) at the hospital, and explain what the insurance company said, and about the locum situation and all, and she goes and eventually talks to one of her superiors, and Friday calls me back and says that if I sign a financial assistance form, the hospital will waive the rest of the charges.

Hooray!
posted by leahwrenn at 7:04 PM on November 6, 2010 [1 favorite]


Update update. So last week, I got another bill, this time saying the charges were more than 90 days past due.

Turns out that the head of billing had received the paperwork, but hadn't yet signed it. So Sandra hassled her about it some more. Apparently now the paperwork is signed, and hopefully the billing company will receive and process the paperwork before the bill is sent to collections.
posted by leahwrenn at 4:37 PM on December 19, 2010


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