ER used a specialist who doesn't take our insurance
July 29, 2019 10:56 AM   Subscribe

My child was in a bloody accident, and ended up in the ER. The ER called in an ortho specialist to take a look ("we've called our ortho guy") , and that specialist sewed him up. Today as I'm scheduling a follow up with the specialist, I find that person doesn't take our insurance.

Since the specialist did the did the surgery, they are claiming we need to do the follow up with them. They did ask us to assent to having the kid sewed up (uh, yeah, what else were we going to do?) but no one mentioned this distinction between the ER and the specialist ahead of time - neither the doc or the hospital staff. The hospital staff did take our insurance info. It's too early for the bills to come in yet, but how screwed are we, and what do I need to do or know in advance? Please help, it's been a horrible 24 hours.
posted by BlueBlueElectricBlue to Health & Fitness (13 answers total) 2 users marked this as a favorite
What state do you live in? This matters as states have different laws on "surprise" medical bills.
posted by ThePinkSuperhero at 11:10 AM on July 29, 2019 [2 favorites]

You might get something from the answers to my recent question.
posted by slidell at 11:20 AM on July 29, 2019

Best answer: You might want to glance at my previous question, depending on where you live. Short answer: I would do everything possible not to see this doc again, as you are probably already on the hook for a multithousand dollar bill.

You need to know that it varies by state, it hugely depends on if you have an HMO or PPO, and if you have ERISA insurance (which is complicated, but you can start with: is this union-provided insurance? If yes, it's probably ERISA). I'm in California, with a PPO, and ERISA-qualified insurance, and we basically got screwed. (Though I fixed it in the end.)

Lastly, one line of attack right now might be to ask this doc for a referral within that hospital system, which should mean that the new doc will have easy access to the records.

Also: sending you love. My insurance crisis also stemmed from my kid ending up in an ER, with a very serious injury, and I remember how hard these first days are. You will get through this. Try to get rest, if possible, and be sure you're drinking enough water and getting some food in. My husband and I had to operate on a tag-team system, trying to structure it so one of us was rested/fed/alert at a time.
posted by BlahLaLa at 11:29 AM on July 29, 2019 [3 favorites]

Best answer: Here is a slightly reassuring set of paragraphs, if you are in California:
In 2016, California passed a law that protected patients from surprise bills from out-of-network doctors they didn’t choose.

This might happen if, for example, a patient went to an in-network hospital and then received a bill from an out-of-network anesthesiologist or radiologist they never even met.

That law covered patients receiving scheduled care like surgery or delivering a baby. Separately, a decade-old California Supreme Court ruling provided similar protections for emergency room patients.
posted by slidell at 11:31 AM on July 29, 2019

Best answer: Sorry to hear about the last 24 hours. In addition to the advice above:

1. Document *everything* (what has happened and what happens going forward). Who told you what and when. What information did you give them, and who did you give it to.

2. Make sure you get full copies of medical records on discharge (or as soon after as possible). Not just the discharge note, but full nurses notes etc. you may have to ask where the hospital medicals record section is and make a request.

3. Call your insurer and just talk to them - mention there was an ER situation, some specialists were used, and maybe just ask if they need anything from you? Document the call. Don't get into "oh they are out of network and I'm worried" etc, but just ask them if they have seen the claims yet and if so when they expect to process them. Be friendly and polite - maybe mention it was for a child and do they have a department who can help finding child medical specialists (some insurers do have teams setup to help if the needs are going to be significant) Ask them for a reference number for this call and *any* call you are on with them for.

4. Check online - at least for my insurer I see things online in their web app *days* or sometimes *weeks* before any physical mail turns up.

Act quickly and reasonably, but don't panic! There are a lot of twists and turns with these situations. Insurers may have multiple reviews they go through, so even if a claim is denied you will have likely several opportunities to fight it inside the insurer and outside.

Good luck.
posted by inflatablekiwi at 11:57 AM on July 29, 2019 [2 favorites]

Best answer: Google "balance billing" and your state. I tried to come up with a comprehensive list of states and their various laws around this practice, but every list I saw left off my own state which does have limited balance-billing protections (I know because this happened to me and I had to send a letter to my insurer letting them know that I know that this practice is illegal). So best to just look up your state and see what the regulations are.

In my case, the law prohibits people with HMO or PPO typed plans (I have an HMO) from being billed for an out of network provider during an emergency situation. I got a bill from the emergency physician group that the doctor who saw me at the (in network) ER I visited after a fall. I was in a financial position to pay the bill so that it didn't go to collection while I was waiting to hear back from the involved parties, so I did that and then wrote a letter to my insurer quoting chapter and verse on the state law prohibiting this very practice. They paid the physician group, and the physician group reimbursed me my original payment.
posted by soren_lorensen at 12:56 PM on July 29, 2019 [1 favorite]

Response by poster: We have a PPO in California, so there may be hope based on that info? I guess I'm not clear on who is going to bill me - the discharge info I have doesn't list the care of the doc who did the procedure.
posted by BlueBlueElectricBlue at 2:03 PM on July 29, 2019

If your insurer takes a pass on covering the doctor's bill, you'll likely get a bill from a random physician group you've never heard of. When I was discharged I didn't even have the name of the doctor's who saw me let alone the group they practiced under. That all was left as an exercise for the reader when a $600 bill showed up a few weeks later.
posted by soren_lorensen at 4:36 PM on July 29, 2019

I'm an emergency physician in San Diego.

If you signed a consent form in the emergency department, you're probably fucked. In California, it almost always says in the consent form itself that the patient is responsible for anything insurance doesn't cover, including out-of-network physicians.
posted by BadgerDoctor at 7:51 PM on July 29, 2019

Do not go to the follow up with the out of network doctor unless you are able to pay for it without the help of insurance. You need to find a doctor in your network. Really.

I had an emergency eye issue that was consulted with a doctor over the phone and that part was out of network. But I was able to find a doctor who was in network for the necessary follow ups. It was a hassle but saved me some money in an already stressful situation.
posted by mightshould at 5:14 AM on July 30, 2019 [1 favorite]

My husband was balance-billed by the out-of-network (!!) on-call orthopedic surgeon at the (in-network) ER, when my husband needed emergency surgery for a broken hip. After several months and a denied appeal from the insurance, I was able to get the hospital to forgive the charge.

But I agree, find an in-network doctor to do the follow up, if possible, if you can’t get the orthopedist to charge you in-network rates.
posted by leahwrenn at 8:50 AM on July 30, 2019

Best answer: I don't know if you can see this thread without being registered, but there's some great info in it: How to Minimize Your Emergency Care Expenses
posted by dancing leaves at 1:16 PM on July 30, 2019 [1 favorite]

Response by poster: Thank you all so much. I was so miserable I couldn't bring myself to come back to this question for a while, but there was tons of useful material here. We took your advice and went to an in-network follow up, and that's been covered. We are going to be balance-billed (and merciful god, ambulance rides are expensive!) but our insurance company has indeed offered to negotiate some of the worst of it, and I wouldn't have known that this was a thing that could be negotiated without your answers. Most importantly, kid's going to be fine (probably just scarring) and our family's trauma-fueled nightmares have subsided, so it all seems more manageable now. At the risk of being maudlin, this site is a precious resource for managing my anxiety through trust-able information, and I appreciate all your help.
posted by BlueBlueElectricBlue at 3:51 PM on September 5, 2019 [3 favorites]

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