Have insurance, so how do I deal with out-of-network charges from the ER?

November 8, 2007 2:52 PM

I am insured through a PPO. I was taken to an out-of-network hospital following an accident with major trauma. Am I out of luck for the charges above and beyond the dreaded "usual, customary, and reasonable" charges?

I was basically unconscious and not in any shape to dictate what insurance I had and where to take me, not that I would have figured the only Level I trauma center in the area wouldn't take my PPO. Whoops.

Now the bills are coming in and while I am certainly not poor, I don't have tens of thousands of liquid dollars to pay off the excessive charges from the hospital. I will likely be at the top of the sliding scale, or off it, since I figure it's based around the poverty line and I make around six figures.

I want to know if I have a legitimate gripe and what my best path of resolution is in order to avoid paying the excess charges. Is the hospital (it's public) likely to chop the charges down if I simply ask? Will I absolutely need to show proof of (lack of) assets, etc.? I am under no impression that the insurance company will be compassionate in this case, so I believe focusing on dealing with the hospital is the best bet.

My best idea at this point is to take the excess (balance) charges after the insurance payments, divide by some number, and offer it in cash upfront. I figure that will end up being 50-100% more than they would have received from me if I had simply paid the 10% copay I would at an in-network facility - rather than 1000% more than I am being billed now. Is that fair, rational, and possible?

Side question: The ER scheduled followup appointments for me at the same out-of-network hospital. My PCP was out of town and his backup was not helpful, nor did the PPO customer service advise me not to have my followups at the same hospital. I feel I was not negligent in trying to avoid out-of-network charges. Do I have a leg to stand on when it comes to protesting the followup appointment benefits?

posted by anonymous to Health & Fitness (4 answers total)

My credentials: I work with the insurance department of a large hospital, specifically, with ER admits. Before handling emergency patients, I worked with admissions that were scheduled beforehand. So, there you go.

When I call an insurance company to say, hey, your member is here, the first thing I need to determine is whether or not the hospital is in their network.

I don't know if you were admitted as an inpatient, or if you we just in ER observation. If you were an inpatient, your hospital insurance verification deparment should have called the insurance, notified them of your admission, obtained authorization, and said to them, "How can we make this be covered at in-plan level?" A lot of times, under a true emergency that can be proven by reviewing the medical records, an insurance will increase the benefit level. ****Many insurances will not be explicit about that, the hospital rep has to ask about this**** I'm not sure what your hospital did, exactly. If you were not admitted as an inpatient, there would likely have not been much of a dialogue, as insurances don't usually require notification of ER visits.

I suggest that you call the billing department of the hospital you went to. Ask them what happened when you admitted, if anyone provided your insurance with clinical information (in other words, the chart notes from your admission) to your insurance to see if they can review you for in-plan benefits. Also, call your insurance company and ask them yourself "what can I or the hospital do to see if I can qualify for in-plan benefits", since it was an emergency situation. You need to ask very pointedly, and anything you don't understand, ask them to clarify. Insurances will NOT be forthcoming with this info.

If it's all a no-go, and you are responsible for the balance, then ask your billing office if you can be screened for financial assistance. Guidelines vary from hospital to hospital for this.

As for your follow-up visits: contact your insurance and ask them if you can get in-plan benefits with an authorization. You will not be automatically given in-plan benefits just because your ER dr referred you. Your PPO is not going to advise you to not keep your follow-up appointments based on reimbursement levels, because a) that's your decision, and b) again, they will not be forthcoming with what is best for you, reimbursement-wise. If you can get better benfits with an authorization, then contact the office of the doctor you are scheduled to visit and let them know that you need them to get an authorization for in-plan benefits. They may either be awesome, and know that already, or be kind of sucky, and not have checked into it. Then call and call your insurance until they can confirm you have the authorization. Take note of the auth number, how many visits it covers, its time-span, who you spoke with, and which department they are with.

If you are not getting anywhere with the follow-up issue, I'd either a) be prepared to suck up a lower benefit, or b) call back your PCP and be more assertive in letting them know what happened to you and that you would like your PCP to either see you himself, or refer you to an in-plan specialist.

Sorry for this epic novel, but this stuff is complicated. Hope this helps.
posted by DrGirlfriend at 3:21 PM on November 8, 2007

This is going to vary very widely depending on your specific insurance plan and the state you live in.
posted by croutonsupafreak at 3:23 PM on November 8, 2007

croutonsupafreak is right that this is insurance-specific. But insurance types (ie, HMO vs PPO), regardless of the particular company, have similar frameworks. What your insurance's guidelines are in particular depends on your company and your particular plan, but general things to ask about, such as authorizations, can be used to navigate lots of insurance plans.
posted by DrGirlfriend at 3:27 PM on November 8, 2007

in addition, maybe find one of those medical bill reviewing services to go over your bills as well? this link may be of use.

Good luck!
posted by potsmokinghippieoverlord at 5:04 PM on November 8, 2007