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:
- Should we start by appealing to the hospital, or the insurance company?
- 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".
- 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.
- 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.