November 23, 2005 6:10 PM   Subscribe

My mother went to the emergency hospital last year and was billed a hefty amount. She was covered with health insurance from her company (Destiny) and the hospital was "in-network". The insurance company paid the hospital fee (which was the larger amount) but only paid about half the physician fee because the physician was "out-of-network". My mother asked whether or not the physician was in-network or out-of-network when she was in the hospital and the nurse just told her not to worry about it. My questions are, 'How can a hospital be in-network and fully covered but assign her an out-of-network physician which won't be fully covered under the insurance?' and 'Is there anything she can do about this? I don't think it's fair she has to pay for something she didn't have a choice in'.
posted by lpctstr; to Health & Fitness (10 answers total) 1 user marked this as a favorite
Vote for a politician who supports single-payer health care, or move to Canada.

In the meantime, go ahead and appeal the insurance claim with the company. Possibly a strategy you can take is to argue that it was emergency care and thus should be covered under those provisions of the policy and not the in-network/out-of-network normal physician care provisions.
posted by jellicle at 7:07 PM on November 23, 2005

Get out the insurance docs and read the fine print, as odious as that may be. Figure out what the denial of benefits appeals processes are, and exhaust them.

Odds are very good that the insurance company will deny benefits on the first appeal (some do as a matter of course). Hopefully the company will pay up when they realize you are tenacious about getting paid. If not, find an attorney who specializes in insurance cases. Sometimes just a letter on legal letterhead is the trigger for an insurance company to honor a benefits claim. Sometimes not.

At some point you'll have to weigh the cost of paying an attorney to sue the insurance company against the cost of just paying the bill, but basically, your only weapons are the internal appeals process of the insurance company and legal action.

And then make sure to vote for single-payer health care supporters from here on out. :)
posted by jennyb at 8:27 PM on November 23, 2005

Best answer: I say this as someone who has worked for a health insurance company for a few years now, and has had to deal with these questions on multiple occasions.

The doctors who provide treatment in the ER do not always, nor do they have to have, the same level of affiliation with the insurance company, as does the hospital. They USUALLY do, but that's more because the hospital wants to maintain those sorts of all-inclusive relationships with insurance companies than anything else. There is a place here in Portland that has a contract with my company and uses non-contracting ER docs, and those ER docs proceed to bill us for charges we never, ever pay. They then turn around and bill those charges (extra fees for night and weekend service, for example) to the patient.

Now, the patient is usually expecting a flat $100 or whatever copayment, because that's how their benefits read. 'Emergency room: $100.' And that is ultimately the grounds on which I suggest your mother file her appeal. She will have a benefit summary, and the summary will in 9 of 10 cases not say anything about 'random off-the-wall charges levied by the gas-passer or the ER doc while you are in the ER.' It WILL have any number of blanket statements where you can be charged for anything anyone feels like anytime, because insurance companies stay afloat through wiggly language. But she will have a good point, focusing on the language that states what she would owe for the ER, so long as it is not so specific as to talk about the different levels of affiliation within an ER (same goes for inpatient treatment, like when a non-contracting doc sees you to check on you after a surgery.)

But how can they do it? Well, most insurance companies require a contracting doctor to have privileges at a contracting hospital (thus not sticking you with the fat hospital bill.) Most insurance companies also protect you from seeing a TOTALLY nonparticipating doctor when you're in a contracting hospital in good faith, the sort of doctor who doesn't accept the company's contracted rate, and bills you the balance for whatever the insurance says they should 'write off.' This situation with your mom is analogous to that. They can keep you from the most egregious of billing cock-ups when you're doing everything you can, and will generally regard this situation as a billing cock-up that needs to be fixed in your favor (hence my earlier advice-- I used to work in the grievance department.)
posted by rebirtha at 9:36 PM on November 23, 2005

Response by poster: Thanks for the responses. The ones about moving to Canada - very helpful.

I contacted the hospital about this since I posted, and they basically just said their charges are according to AMA guidelines etc. rebirtha, it looks like I should be going after the insurance company instead?
posted by lpctstr; at 9:53 PM on November 23, 2005

Go to the insurance company. They're the ones who are paying out dollars. If you were filing a complaint and I was your grievance coordinator (and by 'you' I mean 'your mother' since she does have to either file for herself or appoint you her authorized representative in writing) I'd want to see a description of what went on. Don't dwell on the part where the nurse told your mom not to worry. The insurance company isn't going to hold some nurse responsible for telling your mother not to worry when your mother is in the ER. They can hold themselves responsible, though, for administering your mother's benefits consistently and according to the plan description. So you'll want to dig up the one or two page benefit breakdown and enclose a copy with the ER benefits highlighted, and just briefly say that treatment rendered in the emergency room should be administered according to the plan provisions for ER professional fees. If you could post that information here or email it to me (in my profile) I could be a bit more helpful about where, precisely, their inconsistency is, and how your mother has the best chance of capitalizing on it.
posted by rebirtha at 10:08 PM on November 23, 2005

I had some money tacked onto my bill for my last ER bill--a "night and weekend charge" . Called my insurance, they said it wasn't "usual and customary" so they didn't pay that part. Fair enough, I called the ER services billing and said "my insurance covers ER visits for everything that's 'usual and customary'. This extra charge, according to them, is not such a charge. What's up with that?" (Yes, I did acutally say "what's up with that".

I figured they didn't have any more business charging me those fees than they did charging the insurance them. Or, a different way of looking at it, if the insurance rejected it as overcharging, I'm certainly not going to reach a different conclusion on my own.

In any case, they did the "hold on" thing, and then adjusted the bill. No surcharge. :)
posted by RikiTikiTavi at 10:10 PM on November 23, 2005

RikiTikiTavi, that's slightly different. In your case, the hospital you went to was 'contracting,' and as such, accepts the insurance company's 'usual and customary fee' (or UCR-- usual, customary and reasonable rate) for services rendered. They were billing you what they shouldn't have been, according to their contract, and you pointed it out to them so they took it off. In the case of this place here in Portland, the insurance rejects the charge as outside of UCR, and since the ER doctors themselves have signed no contract with the insurance company, they have no obligation to adjust off those night & weekend charges. What my company does is just pay those charges anyway, on a 'squawk' basis (the patient has to call us and complain) so these non-contracting docs end up getting exactly what they want. But they get it from us instead of from patients, which is how it should be.
posted by rebirtha at 10:31 PM on November 23, 2005

In a similar situation, I was billed $800 and change for "out of network" MD services during an ER visit that led to a brief hospitalization.

When I pointed out to the customer service rep at my insurance company that I had arrvied with a fever of 103, was pretty much out of it and also being given fairly serious pain medication, and thus not exactly in a position to inquire as to the financial affiliations of the doctor who was treating me and his precise corporate relationship to the hospital and the Emergency Room, they covered the "out of network" charges.

Call the insurance company. Be reasonable but firm, and follow up in writing.
posted by enrevanche at 5:43 AM on November 24, 2005

Follow up with the insurance company but also give the hospital a call. They write off a certain amount of this type thing every year.
posted by TheLibrarian at 2:44 PM on November 24, 2005

Response by poster: If anyone is actually reading this, here's how it turned out, with a semi-happy ending -

Called insurance company. They said they wouldn't pay it and call the hospital.

Called the hospital. They said they couldn't do anything about it and call the insurance company.

Called the insurance company. They said call the hospital.

Called the hospital. They said they'd cut it in half. We said we'd pay that.
posted by lpctstr; at 12:26 PM on November 29, 2005

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