Help me dispute my insurance company
June 27, 2015 11:03 AM   Subscribe

My partner was recently in a life-threatening accident, and he went to the closest hospital - which happens to be the only hospital in a 100 mile radius that is out of network for our insurance company. Do we have any recourse?

My partner sustained potentially life-threatening injuries 5 weeks ago, and was transported (by private vehicle - in retrospect should have been an ambulance) to the closest hospital. He presented his insurance card upon entering the ER, and the friends who drove him to the hospital (I was out of state) tried to call our insurance company, but it was a weekend so there was no one working the phones. The hospital never mentioned anything about being out of network, despite very public coverage in our local newspaper (which we didn't know about until later) recently when a dispute between the hospital and insurance company lead to the insurance company dropping this particular hospital. Neither of us have ever been hospitalized before, so we didn't know how this worked.

He was then admitted through the ER, and again filled out paperwork including insurance information.

On the 5th day of his 5 day hospital stay, I received a phone call from our insurance company informing me that the hospital was out of network and we needed to transfer to a different hospital immediately. The insurance company told me that the hospital should have told us upon admission that they were out of network. I have this employee's name written down.

He ended up being discharged that day. The case manager at the hospital also told us the hospital should have informed us upon admission that we were out-of-network.

We have now gotten an EOB - still no hospital bill - that the total cost of the stay was around $17,000 (not including bills from every doctor who actually saw him during the stay) and our insurance company is covering approximately $3,000 of this. The double whammy is that we would meet our in-network out-of-pocket maximum (if this were in network), so now we are on the hook for $14K plus the $8K of our out-of-pocket maximum for the rest of the year. We do not have that kind of money.

Before we got an EOB, I spoke with someone from our insurance company on the phone, who told me that the ER visit was covered in-network since it was a true emergency, but that according to her records it appeared that the whole visit had been listed as "approved in-network." This is not what our EOB now says. She also acted like I was crazy for even worrying about this

Our insurance is a major nationwide company, and we have coverage through my job for the largest employer in our mid-size city. This is one of the two major private hospitals in our city. Bizarrely, each of the doctors he saw - including the hospitalist who works for the hospital - is considered in-network. The $17,000 covered facility fees, labs, imaging, and PT/OT.

The back of my insurance card states "your network provider must call the toll-free number listed below to pre-certify the above services.... in an emergency, seek care immediately, then call your primary care doctor as soon as possible for further assistance and directions on follow-up care within 48 hours." This makes it sound like it is the hospital's responsibility?

I fully understand that we are young and naive and probably should have read the fine print better... but I can't help feeling like this is kind of crazy.

TL;DR Do we have any chance of convincing our insurance company to cover this hospital stay at the in-network rate? I know we can negotiate the bill down with the hospital but the out-of-pocket maximum is a big issue here, as I also have health issues that we are going to be spending money on this year.
posted by raspberrE to Health & Fitness (17 answers total) 2 users marked this as a favorite
Probably not. You're caught in a dispute between the insurance company and the hospital. The insurance company wants to pay less for services the hospital provides but the hospital doesn't think that being in network will result in a big enough increase in patients to make up (and exceed) the difference. You'll probably never be able to get the insurance company to pay the hospital the in-network rate because that's a contract dispute between them. You might, with enough cajoling and work and luck get the hospital to agree to reduce charges and then get the insurance company to pay you back for it. Good luck, sucks to be the little guy caught in a battle between two giants.
posted by Apoch at 11:21 AM on June 27, 2015

Sometimes local Legal Aid clinics have folks whose job it specifically is to help people enroll in insurance or receive adequate and properly billed health care. I don't know if this would fall into their purview, but if you have a local Legal Aid, you could at least start there and see if they know of other resources that might be able to help you navigate this.
posted by WidgetAlley at 11:29 AM on June 27, 2015 [1 favorite]

It is crazy. Welcome to our crazy world. Insurance companies are unfortunately one of the crazier aspects of life that everyone has to deal with.

I don't think that you have an immediate, obvious recourse. The hospital and your insurer are refusing to do business together, and you are caught in the middle. I think your best bet here would be to seek a local advocacy group or a pro-bono attorney who might represent you when trying to settle the bill. But I think it's very unlikely you will get a do-over. The best possible outcome is that the hospital agrees to accept a smaller amount than you owe now and you work out a reasonable payment plan. This kind of scenario is unfortunately more common than you would think.
posted by deathpanels at 11:55 AM on June 27, 2015

What state are you in? Some states (NY in particular) have laws on the books to address this.
posted by ThePinkSuperhero at 11:55 AM on June 27, 2015 [4 favorites]

Does the EOB have a date? If you got it in the mail, it may have been generated before whatever adjustment led to your insurance rep telling you it was covered in-network.
posted by MadamM at 12:38 PM on June 27, 2015

Ok, deep breath!

First thing to know is that it is very very common for EOBs and claim decisions to be appealed, disputed, changed, etc. That your EOB would be wrong on first count is not at all unusual.

You (and the insurance rep you spoke to) are correct that emergency care is billed/covered as in-network.

Be ready with all the facts and call your insurance company back. "I received an erroneous EOB and am calling to have it corrected. This was emergency care and should be paid in-network. In an earlier call on DATE, NAME told me it would be paid in-network. Can you fix this?"

Ask to speak to "appeals" or a supervisor if necessary. (What you are doing is "appealing" a claim.)

You will fix this!! Make an ally at your hospital's billing department who understands that emergency care should be paid in-network and they can help (they probably failed to code as emergency on some of their claims and that is causing the problem - they may need to re-submit.)
posted by amaire at 12:50 PM on June 27, 2015 [17 favorites]

I think you need to get a much clearer handle on what is supposed to happen when you are dealing with an emergency, including the hospital's, your insurer's and your own responsibilities. That will help you clarify what went wrong, whose fault it was, and who should be taking what fraction of the financial hit. Ask questions of the insurer and, if applicable, the HR department of the employer through which you have the insurance.

Generally speaking, I agree with amaire's comment above. Screwy initial EOB's and hospital bills are par for the course. When my wife had (non-emergency, entirely in-network) surgery several years ago, we got all sorts of bills that ended up evaporating. You're going to spend more time and headspace dealing with this than will want to, but the financial problem is likely to end up a lot smaller than it is now.
posted by jon1270 at 12:56 PM on June 27, 2015

I once worked for an insurance company. Please call your state insurance commissioner. They work for YOU, not for the insurance company. If anything can be done, they should be able to help you. They should do it for free.

Also, Nthing suggestions that the first EOB may not be reliable info. An awful lot of claims that involve anything out of the ordinary get botched on the first review just because a lot of claims are processed by people with entry level jobs who review the same basic kinds of claims over and over and basically rubber-stamp stuff they see repeatedly. Laws vary from one state to the next, meanwhile insurance companies tend to be national and thus processing claims for all states and ... basically, insurance is complicated, heavily regulated and all the employees are suffering from information overload. Just start by ASSUMING something went wrong.

Call. Be polite. They get cussed at all day long. Be the customer they WANT to talk to. That can make a difference. Just start with a "gee, golly, whiz, I am so freaked out and surely this must be a mistake. Could you please kindly take a look at this for me?" kind of approach.

But also call your insurance commissioner and talk to them.
posted by Michele in California at 1:32 PM on June 27, 2015 [5 favorites]

If you work for a large employer with a good HR department, this is the kind of thing you can talk to them about too. Your employer is the insurance company's real customer (or they may be self-insured in fact), so the insurance company is at least more likely to listen and be responsive when things come through them. Of course, if your HR department is crappy and views everything as the employees' fault, leave them out of it.
posted by zachlipton at 1:51 PM on June 27, 2015 [2 favorites]

Nthing insurance commissioner. Thats my moms 1st recommendation in situations like this because it works. That said,

For what it's worth, right before my insurance kicked in i went to the hospital for a horrible infection and ended up being billed a huge sum my insurance refused to touch because it was literally 24 hours before the kick in date.

I huffed and puffed and called them repeatedly and filed tons of paperwork and got it reduced to less than 1/3rd the cost on a no interest payment plan.

YMMV, but failing everything else this seems to be a fairly common occurrence from many people i've talked to and a lot of what i've seen on here.

It WAS a huge goddamn hassle though and it involved a shocking amount of mail coming to and from my house.
posted by emptythought at 1:52 PM on June 27, 2015

The only advice I think you should follow is to hire a lawyer who works on insurance cases. Insurance companies almost always fold the moment a lawyer is involved. Even if they do not the lawyer will know how to maximize both your odds and coverage. People who think they have negotiated amounts down are usually being suckered out of full coverage rather than saving themselves money This is an experts game so hire an expert.
posted by srboisvert at 3:53 PM on June 27, 2015

Call the insurance company before you call a lawyer, the insurance commissioner, etc. I agree this has a decent chance of being corrected with a simple phone call. I have no data points about emergency care, but I was once billed about $20K for a surgery that I had pre-approval for, and after a weekend of panicking, found that that it was fixable with a short phone call to the insurance company.
posted by deadweightloss at 4:09 PM on June 27, 2015

Assuming an automobile was involved, what about the automotive coverage? Whether your partner was at fault or not, there's a chance there's some coverage there. In fact, health insurance companies are downright aggressive about going after that coverage to be primary in an auto-related event.
posted by randomkeystrike at 4:58 PM on June 27, 2015 [1 favorite]

Well, this is how it worked for my husband when this happened to him. He went to an ER and was then transferred to a room due to dangerously high creatinine while trying to pass a kidney stone. He was in hospital for a week and we had no idea the hospital was out of our insurance network. Well, after he came home a few weeks later we receive a EOB from our insurance that said we owed the hospital $20,000 because the hospital was not in our insurance's network of providers.

After a sleepless night I call the insurance the next day and they kindly explained I would need to file an appeal due to the fact the hospital just did not code their bill correctly with the transfer from ER to the hospital room. (It should be noted the ER visit was not even an issue, I believe all ER visits are covered by insurance due to emergency visit.)

To do this appeal I had to obtain the hospital records and submit with a form to our insurance, after 60 days I got a response that the bill would be paid by our insurance. (We had already met our deductible for the year.)

If this is what you do, be sure and let the hospital know you are working on an appeal with your insurance company.
posted by just asking at 6:26 PM on June 27, 2015 [3 favorites]

Is your friend conscious and capable of making decisions on WHICH hospital to go to? Or is it "just head for the nearest one or we'll lose him" kind of situation?

ER care is almost ALWAYS treated as in-network (even if the hospital is NOT in network) except in cases of egregious abuse and it doesn't sound like you meet that criteria.

Just appeal it and stop fretting. It won't help. Remember, appeal, appeal, appeal. You can always go to TV station and get a human interest story out of it and insurance will cave, or if your state has an insurance commissioner, contact his department and ask for an ombudsman or such to help.
posted by kschang at 2:43 AM on June 28, 2015 [1 favorite]

First, talk to your company benefits department. They have a ton of pull with the insurance company. If the company is actually self insured, the benefits dept has the power to tell the carrier to pay the claim since they would be paying it with the employer's money. If your employer is inclined to help you, that's the most powerful thing you could have going for you.

Second, take a close look at the EOB and be sure that $17K is the amount that the insurance company would pay, not what the hospital put on their bill. Hospital charges are a pipe dream. Possibly, if the hospital does not have a contract with the carrier, the total is the original, non-negotiated amount. If so, you can probably get the hospital to knock it down to industry standard rates.
posted by SemiSalt at 1:30 PM on June 28, 2015

Response by poster: Thanks for all the answers so far.

To clarify:

They are definitely covering the actual ER visit at the in-network rate. However, the subsequent 5 days inpatient are not currently being covered in-network, even though he was admitted via the ER.

It was not an auto accident, so our auto insurance doesn't come in to play.

And unfortunately, my employer's HR department is a farce.

We do have a friend-of-a-friend lawyer who has offered to assist, so that's probably the route we will go. Will also look in to our state insurance commissioner.
posted by raspberrE at 10:25 AM on June 29, 2015

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