How do I get insurance to cover an out of network emergency room visit?

December 28, 2021 9:39 AM

Last week, my daughter fell out of our baby carrier and hit her butt and then head on the floor. We called our pediatrician, and they recommended taking her to the emergency room at a local children's hospital, which I did. Later, I realized the hospital was out of network for my insurance. Help?

She was seen by three doctors and observed for about two hours, but there weren't any additional tests done and she wasn't hooked up to anything. But still, I know this is going to be expensive, and I'd love some tips on how to navigate working with my insurance company to get this covered.

My thoughts are that since it was an emergency, and our doctor told us to go, and to go to a specific hospital, we should be on okay footing, but any advice is welcome.

She's fine, by the way.

Thanks!

posted by Fister Roboto to Health & Fitness (11 answers total)

"[Today's interim final rule bans] surprise billing for emergency services. Emergency services, regardless of where they are provided, must be treated on an in-network basis without requirements for prior authorization."
posted by saeculorum at 9:42 AM on December 28, 2021 [3 favorites]

What state are you in? Different states have rules already in place about surprise bills. The federal rule goes into effect 1/1/2022 so you just missed that one.
posted by ThePinkSuperhero at 9:48 AM on December 28, 2021

Response by poster: FWIW, I spoke to a "financial counselor" from the hospital the next morning, and they said that getting it covered in-network would be a process, and if it didn't work, they would help me develop a payment plan.

I too read that emergency room visits should be covered as in-network, but hearing that kind of gave me pause.

I'm in Wisconsin.
posted by Fister Roboto at 9:49 AM on December 28, 2021 [1 favorite]

Wisconsin does not have a surprise billing law, unfortunately. However your individual insurance provider may have its own policy. Regardless, make sure to check the hospital's financial assistance policy. Financial counselors don't like to tell you about them up front, in my experience. Depending on your income level you can get the cost reduced or waived entirely. From experience I know that Froedtert and Ascension both have them if it happened to be one of those hospitals. It's a good back-up if insurance doesn't pan out.
posted by brook horse at 10:41 AM on December 28, 2021

I don’t know if this will work retroactively but a phrase you can try is a “single-case agreement” — this means a one-off agreement to reimburse an out of network provider at in-network rates. Is that worthwhile? Without knowing what the structure of your insurance looks like it’s hard to know, it certainly would be a process.
posted by chesty_a_arthur at 11:05 AM on December 28, 2021 [2 favorites]

Step 1 would be to see if you can find a summary of the your insurance plan coverage. That usually gives the you the high level overview of what is covered. Some plan will cover any ER visit, some would cover it at out of network rates (if you have OON coverage, some (like Kaiser) will only cover an out of network ER if you are not near an in-network facility. That will give you some idea of what is likely to happen. Then you probably need for the claim to be processed before you take the next step and that will probably take a couple of weeks so I would try to just put this out of your mind until you know what you are dealing with.
posted by metahawk at 12:07 PM on December 28, 2021 [1 favorite]

I just looked up my own coverage - there is an important twist in that non-network coverage requires 'prior authorization' be obtained within 48 hours. There is also a different rate of coverage for "true emergency" and "non-emergency" for out of network ER care. So, I would urge anyone reading this to take a minute and check your own coverage - it's not something I would have thought about.

Things should get better with the no surprises act but the initial Jan 1 rules only cover people who are not insured or not using their insurance.
posted by metahawk at 2:33 PM on December 28, 2021

That’s a pain. I’m glad you spoke to the hospital about it as that would’ve been my first suggestion. It sounds like they will come through for you. If not, two other options with the hospital besides a payment plan are financial aid (they will take the circumstances into account) and making a paid-in-full arrangement between you and the hospital (will probably require lump sum.)
posted by michaelh at 2:49 PM on December 28, 2021

Response by poster: I looked at my insurance coverage summary, and it said that I'm responsible for a $75 copayment, even if the hospital is out of network, but surely there is more to it than that?
posted by Fister Roboto at 4:04 PM on December 28, 2021

Re: the $75 coypay payment -- perhaps there is another number on there for an out-of-network deductible?
posted by joeyjoejoejr at 7:12 AM on December 29, 2021

There must be coinsurance rates listed somewhere for in- and out-of-network. ER/hospital visits are almost always a coinsurance rate plus an ER deductible if you're not admitted (basically an extra $75 fee from you, in your case.)

Having the same ER deductible and coinsurance rate is fairly common, the difference in coverage being the annual out-of-pocket maximum for out-of-network.

Hopefully that's all irrelevant due to the hospital and insurer making this in-network or you finding another way to bring the bill down.
posted by michaelh at 1:34 AM on December 30, 2021