Home Forums Hunting & Shooting Hunter's Campfire Anthem declines claim for woman's valid reason to ER

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Woman experiences pain , decides it might be serious, goes to ER, turns out its ovarian cysts, gets bill from hospital for $12K, Insurance declines it - tells her it wasn't a medical emergency.

https://www.cbsnews.com/news/anthem-among-health-insurers-refusing-to-pay-er-bills-doctors-say/

sounds like part of their motivation is the prescription drug and heroin crisis is eating their lunch

The story ends ok for the woman, she sought an appeal , the bill was eventually paid, but this could be a trend that affects everyone - pushing insured people to avoid the ER.

You are either young or naive to be surprised by this.
Nothing new. Many insurance companies first move is to deny a claim. The bean counters know many will not appeal.

Of course. They deny payment for the best meds i prescribe all the time.

Why spend billions for new, better drugs when ins cos will never pay for them.

Before I retired, my insurance was BC/BS. On two occasions, they refused to pay the ER doctors charges because he was not on their list of approved doctors. What was happening was that the local hospital was bringing in doctors to cover on weekends, and holidays and the such. My hospital charges would be covered, but not the doctor.

My wife is really good at "negotiating" and she was on the phone for hours with the insurance company, the hospital, and the doctors office. Her point was......first off, the hospital should not bring in outside help unless that help is going to be considered a "preferred provider" like the rest of the hospital is. Secondly, emergency means just that, and since there was no other choice we had as to the doctor, BC/BS should have to pay.

In both case, the insurance covered the charges. Turns out the head of the ER was partly responsible for the mix up.

at $12K what option would you have?

Check your state laws. Colorado (and many other states as I understand it) has a law that says if you go to an "in-network" facility and are treated by someone who is "out of network," you as the patient are only responsible for the in-network negotiated charges. The rationale being, you have no way of knowing the status of or controlling who treats you. In many states the out-of-network provider is prohibited from billing you for the balance, but not in Colorado. They can send you a bill, but you don't have to pay it in other words.

I know this because it happened to me two years ago. I had wrist surgery in an in-network facility with an in-network surgeon but there was an out-of-network assistant in on the surgery. The friggin' assistant tried to bill me for about four times what the surgeon was paid. My insurance company paid him the negotiated rate but he wanted me to pay his ridiculous balance. It's an insidious practice called "balance billing." I just sent a letter to his collection agency citing the law and telling them to pound sand.

Haven't heard back.

Yeah, those cheapskate MF'rs are SOOO much smarter than your doctor.

Right?

First time that happened to me, was the very day I cancelled that insurance.

Not happened with BC/BS. Hope it doesn't.

This is easily avoided.

Call you Dr to make an appointment.

They will most likely tell you you have to wait for several days,weeks or months.

Tell the receptionist that the pain is so bad I can't wait that long.

She will "recommend" you go directly to the ER.

Problem solved, your doctor's office "told" you to go to the ER.

Not 'many' - the reality is "most".. To some extent, yes.. But, with persistence, it usually gets approved...

My wife says Humana's the worst... She has to deal with those bastids every week..

If need be, pay the bill.

But if they send me a $12k bill, you can bet I will negotiate it down just like insurers and pay it right away.

If need be, pay the bill.

But if they send me a $12k bill, you can bet I will negotiate it down just like insurers and pay it right away.

You can blame a lot of the doc in box stand alone ER’s. Those things have sprung up to take advantage of ER billing rates. They look pretty much like the normal urgent care place except they say Emergency in them. My wife took our (at the time) ten year old to the first one that opened up here for a sinus infection. It was the first one around here and she thought it was just like the other urgent care places. They tried to bill $3,500 for what amounted to a steroid shot. As that we have a big deductible, we would have paid all that. I called them and told them that I would pay $250 and they said “Fine”.

It is a huge racket and I don’t blame the insurance companies one bit. If, as it turns out it was a legitimate emergency they’ll get approved upon reconsideration.

When my sister in-law was still alive, she and her husband were visiting family in IL for Christmas. She had a spell (she had colon cancer) and her husband took her to the nearest ER. She was admitted and given an emergency radiation or chemo treatment. Since he was AD Army, they were under Tricare. Tricare denied the claim and they were stuck with a $20,000 bill. He fought Tricare over it, and lost. She died a few months later, and luckily he got the $100,000 life insurance pay out, and $20,000 of it went to pay for that hospital visit.

I had a back fusion last November. I got a bill in the mail for $380,000 from the hospital with a note saying to please contact my insurance provider or make payment arrangements with the hospital. I was AD Air Force at the time, so I had no co-pay on my end. Tricare paid the hospital within 20 days, but I have gotten numerous bills up until September of this year for piddly crap. They were not supposed to bill me either as again I was AD Air Force and they had the agreement with Tricare saying they could not bill me. I finally gave up fighting with Alaska Regional and Tricare and paid the bill as they threatened to send me to collections.

Many times it's not the insurance companies fault

I recently had an outpatient knee surgery. Insurance paid the doctor portion, but not the facility saying it was "experimental". Called them, said 'you realize how dumb that sounds, that you paid for the procedure, but not the bed I laid on?" They agreed and looked into it, in under 2 minutes I had my answer: the submitting facility coded it wrong. the insurance gave me the right code, called the facility (after they sent me a bill) and said "re-submit with this code" they did, problem solved.

Literally 1/3 of medical cost these days is billing. That's why most primary docs offices give you a 30% self-pay discount.

That's not my experience, at least with hospitals. Insurance companies pay about 30 cents on the dollar, but if you don't have insurance, they come after you for full freight.

There's a reason they always talk about "doctors and lawyers" together....

Thank Satan and Leroy for Zero the hero.

Coding mix ups are going to happen. My issue is why an ED visit comes to $12000. I have seen the increase in diagnostic studies and treatments in the ED over time, and frankly don't understand it. I did emergency medicine for 17 years, and it's changed a lot since then. It would be interesting to see the itemized bill for that visit. Free standing EDs are another problem. It's estimated that we waste about 30% of our health care dollars and I see it every day.

A old friend's mother was hospitalized, dying from terminal cancer, and in her final days.

He said one evening after visiting her that he couldn't understand with what little time she had left, measured in hours or at most days, not weeks, why they keep waking her up and disturbing her all hours of the night and day, for more and more x-rays, drawing blood, tests, random treatments and examinations of all kinds, by any and everyone wearing a stethoscope.

I told him my guess was probably because they were trying to drain every last cent her insurance allowed for every procedure covered before she died.

My girlfriend has run coding and billing for hospitals and doctors. She hates insurance companies and over billing medical providers. She told me that unlike dentists and vets doctors and hospitals have to offer a payment plan. She recommends that if they are pulling over billing and endless bills ask for a payment plan. When they ask how much you can afford per month tell them ONE DOLLAR.
Also she claims many of the billers and coders are dumb as rocks and make mistakes all day long.