Health Insurance Out of Network ruling issue

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Topic Author
Battleborn33
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Health Insurance Out of Network ruling issue

Post by Battleborn33 »

My wife and I have health insurance coverage thru Select Health, which has a primary coverage area of Idaho and Utah. I purchased a policy which includes extended in-network coverage outside of those two states for urgent and emergency care.

In March my wife had an accident while hiking in Arizona, she dislocated her ankle and broke both her tibia and fibular, she had to be extracted from the mountains where we were hiking by helicopter, it was a serious accident. She was treated on the day and evening of the accident at an Emergency Room and the decision was made by the surgeon to delay the required surgery for a few days to allow the swelling to go down. The accident occurred on a Thursday afternoon and she had surgery the following Tuesday morning.

Select Health is treating everything that happened on the day of the accident as in-network and applying it to our in-network deductible, however they are coding the surgery and all the follow-up as out of network and of course the out of network deductible is HUGE. The doctor and the facility where the surgery took place are both IN the extended network coverage we have, we have not been provided a reason for the decision to code everything post day of accident out of network.

We have a letter from the doctor advising this was all one incident and that she was not able to travel for surgery, she couldn't travel for some time after either. I'm at a loss to understand what Select Health expected us to do different. On a very traumatic day was I supposed to question the doctor's decision as to when to operate?

I plan to appeal the decision of the surgery and follow up care being out of network. I hoping to find someone with experience with a similar situation who could provide some insight and guidance as to why most of her care is being considered out of network and what I might do to increase our chances of a successful appeal.

ON another topic, it's now 3 months since her accident and surgery and we have received a single invoice, it's from the anesthesiologist, no others. We fortunately have very little experience with the health care system, but is this normal? I see the claims that were sent to the insurance company, that's how I know how Select Health coded them, but no invoices from the providers yet.
OnTrack2020
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Re: Health Insurance Out of Network ruling issue

Post by OnTrack2020 »

So the doctor and facility are considered in-network.

Have you called Select Health to ask why?

Would this be considered part of the No Surprises Billing Act?

I'm wondering if your insurance company considered that, at the point when your wife was stabilized, that it then was no longer an emergency? It still doesn't explain if the doctor and facility are in-network why they would have charged as out-of-network.

Edited to add: Your wife is, at some point, also probably going to also need physical therapy services. You are probably going to want to check if your insurance is going to cover that at the in-network rate.
jeam3131
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Re: Health Insurance Out of Network ruling issue

Post by jeam3131 »

I don't think your doctor is doing the coding as in network and out of network. That's the way your insurance is processing it.

Find your insurance plans SPD, or summary plan description document. Some insurances call it evidence of coverage. It should be a few hundred pages. Read the rules about what it says for in network and out of network coverage. Most instances will cover out of network services in an emergency with in network rates.

Then call your insurance company. Find out why they are considering part of the stay as out of network. It's possible that the anesthesia and radiology are not part of the hospital and are out of network. Luckily, the no surprises act should protect you here.
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ResearchMed
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Re: Health Insurance Out of Network ruling issue

Post by ResearchMed »

You might want to consider contacting your state's Insurance Commissioner's Office.
Even if the insurer hasn't finalized things yet, if they are still processing it this way, you may want to preserve any appeal option by starting something before any deadline.

This doesn't make sense...

Good luck.

RM
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simplextableau
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Re: Health Insurance Out of Network ruling issue

Post by simplextableau »

You will want to make sure you don't miss the appeal deadlines. Others can chime in on inexpensive ways to convince the insurer that you should attempt first, but this sort of bad faith conduct is not uncommon. I have seen it firsthand, including an insurer claiming that an ICU stay was not medically necessary contrary to all the treating physician's opinions. They cherry pick medical records and play games.

The last resort, should lesser methods fail, is to hire a lawyer who for a few thousand dollars reviews the medical records and writes a very detailed 10 page or so letter explaining why all the treatment was medically necessary and falls under the coverage in the policy, and demands the insurer pay the claim or face bad faith litigation. That usually convinces the insurer to see the light. Hopefully you won't need to do that.
PaunchyPirate
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Re: Health Insurance Out of Network ruling issue

Post by PaunchyPirate »

It is not uncommon for a hospital or doctor to not send you a bill until they have resolved any differences they have with the insurance companies. Not all do it this way, but I have seen it.

Most recently, I had a biopsy done in the operating room. The insurance claims were filed in a very timely manner (a week or 2 after the procedure). I saw quite quickly what the doctors/hospital were asking for from the insurance company via my insurance company's website. I was a little nervous, because there were many confusing claims that showed a lot of money being asked for and my insurance company was saying they wouldn't pay nearly as much (as expected). The claims were paid within a week or 2 after they were filed. The primary doctor and anesthesiologist's bills quickly came in and matched up to insurance claims. But the hospital's facility charges (far more complex) did not get billed to me for 2 more months. But in the end, what they billed me matched up to what my insurance said I should have to pay.
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Artful Dodger
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Re: Health Insurance Out of Network ruling issue

Post by Artful Dodger »

Full disclosure- I work in the health insurance/ employee benefits area.

Your emergency was on Thursday when the accident occurred. The follow up surgery on Tuesday would not be considered emergency care unless your extended policy specifically included follow up care. You did have two business days to call your insurance company after the accident to ask how services would be covered. I’m also a little surprised the provider didn’t do some type of benefit check prior to the surgery being scheduled.

I think you have a shot at getting it paid, but you’re going to have to work with the company and with the providers. A lot of the time, insurers will have back up participation in a national PPO network which could help. If the providers (surgeon, anesthesiologist, other docs, and hospital or clinic) are willing to negotiate with the insurance company so the cost is comparable to what they would see in network, that’s your best hope.
Cautionary Tale
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Re: Health Insurance Out of Network ruling issue

Post by Cautionary Tale »

Someone suggested hiring a lawyer for a few thousand. Wondering what the out of network deductible is?

This is my worst case scenario. My ACA plan has an unlimited out of network max. Biggest drawback to the policy.
DarkHelmetII
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Re: Health Insurance Out of Network ruling issue

Post by DarkHelmetII »

I would also add that, generally speaking, one's exposure to out-of-network claims cost can substantially exceed the out-of-network Out of Pocket Maximum (OOPM). The reason is that only "usual and customary" charges count toward the OOPM. Everything above "usual and customary" or whatever verbiage is buried in the legal language could become the patient's responsibility.
jeam3131
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Re: Health Insurance Out of Network ruling issue

Post by jeam3131 »

Artful Dodger wrote: Mon Jun 13, 2022 12:47 pm Full disclosure- I work in the health insurance/ employee benefits area.

Your emergency was on Thursday when the accident occurred. The follow up surgery on Tuesday would not be considered emergency care unless your extended policy specifically included follow up care. You did have two business days to call your insurance company after the accident to ask how services would be covered. I’m also a little surprised the provider didn’t do some type of benefit check prior to the surgery being scheduled.

I think you have a shot at getting it paid, but you’re going to have to work with the company and with the providers. A lot of the time, insurers will have back up participation in a national PPO network which could help. If the providers (surgeon, anesthesiologist, other docs, and hospital or clinic) are willing to negotiate with the insurance company so the cost is comparable to what they would see in network, that’s your best hope.
I'd say the surgeon, anesthesiologist, other docs etc won't have any role or say in this. Its all going to be hospital billing
Topic Author
Battleborn33
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Re: Health Insurance Out of Network ruling issue

Post by Battleborn33 »

Artful Dodger wrote: Mon Jun 13, 2022 12:47 pm Full disclosure- I work in the health insurance/ employee benefits area.

Your emergency was on Thursday when the accident occurred. The follow up surgery on Tuesday would not be considered emergency care unless your extended policy specifically included follow up care. You did have two business days to call your insurance company after the accident to ask how services would be covered. I’m also a little surprised the provider didn’t do some type of benefit check prior to the surgery being scheduled.

I think you have a shot at getting it paid, but you’re going to have to work with the company and with the providers. A lot of the time, insurers will have back up participation in a national PPO network which could help. If the providers (surgeon, anesthesiologist, other docs, and hospital or clinic) are willing to negotiate with the insurance company so the cost is comparable to what they would see in network, that’s your best hope.
Artful Dodger, thank you for your reply. I provided all my insurance info to the ER attending on the evening of the accident because she was speaking to the surgeon and his office regarding coverage and they came back and advised that they were going to discharge my wife and do the surgery a few days later to allow the swelling to go down. They gave me the impression they had checked with the insurer, but perhaps they were just relying on experience?

I did call my insurance before the surgery and was advised that is "might" not be in-network because she had been discharged but we had no real alternative at that point, my wife had a foot that pointed the wrong direction and two jagged bone ends in her leg, had to have the surgery. We could not have returned to a facility in Utah or Idaho to have the surgery, too great of a risk. The surgery was a continuation of the incident and it occurred on the timeline the doctor specified, it seems unreasonable to expect that we would have known to dispute that on the night of the accident, especially because it was a traumatic day, she was hoisted off the mountain in a helicopter.

I have a letter from the doctor that specifies it's all one incident, I'll be including that with my appeal.

Do you have any suggestions for additional information to include with the appeal? Or any insight on the chances of getting this changed?
JDave
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Re: Health Insurance Out of Network ruling issue

Post by JDave »

Do NOT try to settle this over the telephone!

Put everything in writing, and send each and every letter Certified Mail Return Receipt Requested.

I cannot emphasize enough that dealing with medical billing issues over the telephone is the wrong way to handle matters.
student
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Re: Health Insurance Out of Network ruling issue

Post by student »

Let me say that I know nothing about insurance so what I say is probably worthless. If you use one wrong word, they may use it to deny you. I suggest you hire an advocate who knows how to talk to them.
OnTrack2020
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Re: Health Insurance Out of Network ruling issue

Post by OnTrack2020 »

Battleborn33 wrote: Mon Jun 13, 2022 1:33 pm
Artful Dodger wrote: Mon Jun 13, 2022 12:47 pm Full disclosure- I work in the health insurance/ employee benefits area.

Your emergency was on Thursday when the accident occurred. The follow up surgery on Tuesday would not be considered emergency care unless your extended policy specifically included follow up care. You did have two business days to call your insurance company after the accident to ask how services would be covered. I’m also a little surprised the provider didn’t do some type of benefit check prior to the surgery being scheduled.

I think you have a shot at getting it paid, but you’re going to have to work with the company and with the providers. A lot of the time, insurers will have back up participation in a national PPO network which could help. If the providers (surgeon, anesthesiologist, other docs, and hospital or clinic) are willing to negotiate with the insurance company so the cost is comparable to what they would see in network, that’s your best hope.
Artful Dodger, thank you for your reply. I provided all my insurance info to the ER attending on the evening of the accident because she was speaking to the surgeon and his office regarding coverage and they came back and advised that they were going to discharge my wife and do the surgery a few days later to allow the swelling to go down. They gave me the impression they had checked with the insurer, but perhaps they were just relying on experience?

I did call my insurance before the surgery and was advised that is "might" not be in-network because she had been discharged but we had no real alternative at that point, my wife had a foot that pointed the wrong direction and two jagged bone ends in her leg, had to have the surgery. We could not have returned to a facility in Utah or Idaho to have the surgery, too great of a risk. The surgery was a continuation of the incident and it occurred on the timeline the doctor specified, it seems unreasonable to expect that we would have known to dispute that on the night of the accident, especially because it was a traumatic day, she was hoisted off the mountain in a helicopter.

I have a letter from the doctor that specifies it's all one incident, I'll be including that with my appeal.

Do you have any suggestions for additional information to include with the appeal? Or any insight on the chances of getting this changed?
Yes, definitely appeal.

The doctor says that it's all one incident. Follow-up care usually stems from one incident and is tied to the original incident. That follow-up care doesn't necessarily make it an emergency. In your wife's case, I would disagree.

When I broke my ankle, once they stabilized the foot in ER, I was discharged. Then 4 days later, I had surgery. That wasn't necessarily an emergency to the insurance company, but it was to me. I was in tremendous pain, and I couldn't even imagine trying to travel---heck, we live 7 minutes from the hospital and I had to crawl into our home after being discharged.

I would be very strong in your letter regarding the "orthopedic emergency" and "gross deformity" that your wife suffered, and travel back to the area where you live wasn't possible, but am sure your doctor probably wrote his letter as such, especially as there is a lot of swelling going on.

Have you looked into the No Surprises Billing Act in regard to post-stabilization care and see if, by chance, it applies to your wife's situation?

Edited to add: Did you have any medical travel insurance, by chance? Also, how was the medical helicopter bill handled? Did the EOB show as being paid on that?
Topic Author
Battleborn33
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Re: Health Insurance Out of Network ruling issue

Post by Battleborn33 »

Thank you for the suggestions. The helicopter extraction was performed by Maricopa Search & Rescue, it's wasn't a medivac helicopter, we were inside a wilderness area. Search and Rescue got her out and took her to the highway where she was transferred to a waiting ambulance. Maricopa County (county Phoenix is in) doesn't bill for search and rescue so the helicopter was no charge.....a very nice surprise to us!
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Picasso
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Re: Health Insurance Out of Network ruling issue

Post by Picasso »

Artful Dodger wrote: Mon Jun 13, 2022 12:47 pm Full disclosure- I work in the health insurance/ employee benefits area.

Your emergency was on Thursday when the accident occurred. The follow up surgery on Tuesday would not be considered emergency care unless your extended policy specifically included follow up care. You did have two business days to call your insurance company after the accident to ask how services would be covered. I’m also a little surprised the provider didn’t do some type of benefit check prior to the surgery being scheduled.

I think you have a shot at getting it paid, but you’re going to have to work with the company and with the providers. A lot of the time, insurers will have back up participation in a national PPO network which could help. If the providers (surgeon, anesthesiologist, other docs, and hospital or clinic) are willing to negotiate with the insurance company so the cost is comparable to what they would see in network, that’s your best hope.
Another health insurance management role here. This is correct.

No Surprises Act only applies to emergency care and the subsequent surgery is not considered emergency care.

Hospital prob only did eligibility check and no OON digging. Standard I think.

I’m sorry this happened to you, but you bought a less expensive plan and happened to have an accident where your plan has leaner coverage. Maybe consider a more comprehensive plan in the future.
Northern Flicker
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Re: Health Insurance Out of Network ruling issue

Post by Northern Flicker »

jeam3131 wrote: Sun Jun 12, 2022 9:15 pm I don't think your doctor is doing the coding as in network and out of network. That's the way your insurance is processing it.

Find your insurance plans SPD, or summary plan description document. Some insurances call it evidence of coverage. It should be a few hundred pages. Read the rules about what it says for in network and out of network coverage. Most instances will cover out of network services in an emergency with in network rates.

Then call your insurance company. Find out why they are considering part of the stay as out of network. It's possible that the anesthesia and radiology are not part of the hospital and are out of network. Luckily, the no surprises act should protect you here.
If the insurance company is only processing the emergency care as in-network, it is hard to see what the extended benefit is, assuming this is an ACA-compliant plan (which is a broader criterion than it being sold on an individual exchange, but would include such individual plans). That’s because the emergency care is always in-network for an ACA-compliant plan.
Last edited by Northern Flicker on Tue Jun 14, 2022 12:36 am, edited 1 time in total.
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Picasso
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Re: Health Insurance Out of Network ruling issue

Post by Picasso »

Also, to those who are advising an appeal, know that only ~15% of cases are overturned on appeal. Not saying don’t try it, but set expectations appropriately.
TIAX
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Re: Health Insurance Out of Network ruling issue

Post by TIAX »

Picasso wrote: Tue Jun 14, 2022 12:29 am Also, to those who are advising an appeal, know that only ~15% of cases are overturned on appeal. Not saying don’t try it, but set expectations appropriately.
A fair point. Keep in mind that if you're considering bringing suit, you may need to appeal internally twice to exhaust your administrative remedies.
jeam3131
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Re: Health Insurance Out of Network ruling issue

Post by jeam3131 »

Picasso wrote: Tue Jun 14, 2022 12:29 am Also, to those who are advising an appeal, know that only ~15% of cases are overturned on appeal. Not saying don’t try it, but set expectations appropriately.
very true. in most cases, they dont even read them. they've already made up their mind before they even get past the first sentence. they have no incentive to overturn their own decisions. they would much rather have people just give up
DarkHelmetII
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Re: Health Insurance Out of Network ruling issue

Post by DarkHelmetII »

1) If an employer sponsored plan, reach out to regional ERISA Office. They will require that all appeals are exhausted.

2) If not associated with an employer (e.g. purchased on the "exchange") contact state DOI.
Northern Flicker
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Re: Health Insurance Out of Network ruling issue

Post by Northern Flicker »

jeam3131 wrote: Tue Jun 14, 2022 7:10 am
Picasso wrote: Tue Jun 14, 2022 12:29 am Also, to those who are advising an appeal, know that only ~15% of cases are overturned on appeal. Not saying don’t try it, but set expectations appropriately.
very true. in most cases, they dont even read them. they've already made up their mind before they even get past the first sentence. they have no incentive to overturn their own decisions. they would much rather have people just give up
The 2nd appeal is an external review, at least in the state where I live.
jeam3131
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Re: Health Insurance Out of Network ruling issue

Post by jeam3131 »

Northern Flicker wrote: Tue Jun 14, 2022 12:57 pm
jeam3131 wrote: Tue Jun 14, 2022 7:10 am
Picasso wrote: Tue Jun 14, 2022 12:29 am Also, to those who are advising an appeal, know that only ~15% of cases are overturned on appeal. Not saying don’t try it, but set expectations appropriately.
very true. in most cases, they dont even read them. they've already made up their mind before they even get past the first sentence. they have no incentive to overturn their own decisions. they would much rather have people just give up
The 2nd appeal is an external review, at least in the state where I live.
correct, i was referring to the first line appeal. its a total joke
investorpeter
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Re: Health Insurance Out of Network ruling issue

Post by investorpeter »

Picasso wrote: Tue Jun 14, 2022 12:23 am
Artful Dodger wrote: Mon Jun 13, 2022 12:47 pm Full disclosure- I work in the health insurance/ employee benefits area.

Your emergency was on Thursday when the accident occurred. The follow up surgery on Tuesday would not be considered emergency care unless your extended policy specifically included follow up care. You did have two business days to call your insurance company after the accident to ask how services would be covered. I’m also a little surprised the provider didn’t do some type of benefit check prior to the surgery being scheduled.

I think you have a shot at getting it paid, but you’re going to have to work with the company and with the providers. A lot of the time, insurers will have back up participation in a national PPO network which could help. If the providers (surgeon, anesthesiologist, other docs, and hospital or clinic) are willing to negotiate with the insurance company so the cost is comparable to what they would see in network, that’s your best hope.
Another health insurance management role here. This is correct.

No Surprises Act only applies to emergency care and the subsequent surgery is not considered emergency care.

Hospital prob only did eligibility check and no OON digging. Standard I think.

I’m sorry this happened to you, but you bought a less expensive plan and happened to have an accident where your plan has leaner coverage. Maybe consider a more comprehensive plan in the future.
I'm genuinely curious because this is a scenario I worry about while traveling. If OP did contact the insurer and was informed that the surgery would be considered out-of-network, what option would they have for obtaining the surgery in-network? To travel back home against medical advice?

For many, there is no option to obtain any meaningful out-of-network coverage, at any cost.
Northern Flicker
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Re: Health Insurance Out of Network ruling issue

Post by Northern Flicker »

investorpeter wrote: I'm genuinely curious because this is a scenario I worry about while traveling. If OP did contact the insurer and was informed that the surgery would be considered out-of-network, what option would they have for obtaining the surgery in-network? To travel back home against medical advice?
When there are no in-network providers in the location where care is needed, I think how it will play out depends in part on the insurer. Kaiser, for instance has a formal policy and a travel number to call within 24 hrs of starting care or as soon as is feasible. They discuss with the attending physician whether it would be feasible to move the patient to a Kaiser facility, and will approve care as in-network when relocating for care is infeasible. Some insurers have more ambiguously worded policies so you never know fully where you stand until a claim is processed.
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ResearchMed
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Re: Health Insurance Out of Network ruling issue

Post by ResearchMed »

investorpeter wrote: Tue Jun 14, 2022 2:30 pm I'm genuinely curious because this is a scenario I worry about while traveling. If OP did contact the insurer and was informed that the surgery would be considered out-of-network, what option would they have for obtaining the surgery in-network? To travel back home against medical advice?

For many, there is no option to obtain any meaningful out-of-network coverage, at any cost.
[emphasis added]


"while traveling..." there is travel insurance.

We always get that when out of the country, but the coverage we get would also include travel within the USA.

There are quite a few different types of policies; many include insuring the costs of the travel itself, such as non-refundable cruise or resort expenses along with medical coverage.
And for the medical coverage, there are many different limits available, as well as restrictions, so pay attention to the small print.

Better yet, contact a travel insurance agent or broker (someone who deals with several different travel insurers). They can help one get the best possible coverage given one's concerns.
To have the best choice of coverages, it's important to start the coverage within 10-20 days of the FIRST payment (even if it is a refundable deposit; one only needs to insure the deposit and add coverage as more payments are made). The amount of time varies with the policy and the state of residence (USA-resident based coverage).
One important type of coverage to pay attention to are policies with restrictions about "pre-existing conditions". This is defined differently than we typically think about it in everyday life.
And pay attention to the policy limits for medical coverage. It varies considerably.

Travel insurance for medical coverage typically has nothing to do with "in network" or not. It just pays the costs, as long as it's not excluded and doesn't exceed the coverage maximum.

The types of policies we get also include coverage for losses of the travel costs as well as medical costs, but there are policies that focus on the medical care.

We use www.TripInsuranceStore.com and others here on BH also have had good experiences with them.

In our case, we have had quite a few claims (unfortunately), including some large claims. All have been paid without any nonsense.

Whether one wants to have this extra coverage is a personal choice, obviously. However, it's not the case that "...there is no option to obtain any meaningful out-of-network coverage, at any cost."
And it doesn't even need to be expensive, although cost would vary by situation.

RM
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cubs1999
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Re: Health Insurance Out of Network ruling issue

Post by cubs1999 »

Just wanted to add for OP or others that there may be some money available from credit card accident insurance. For example, the Chase Sapphire Reserve, will give up to $2500 as part of an emergency medical benefit as quoted below from benefit guide. Some who have some of these premium travel credit cards may not even know about this benefit. it isn't much, but might still be an extra $2,500 some might even know to claim.

Emergency Medical and Dental
The Emergency Medical/Dental Coverage provides
reimbursement for Emergency Treatment if You become sick
or accidentally injured while traveling on a Covered Trip up to
two thousand five hundred ($2,500.00) dollars and is subject
to a fifty ($50.00) dollar Deductible. If You are hospitalized as a
result of a covered accident or sickness during Your Covered Trip,
and Your attending Physician determines that You should recover
in a hotel immediately after Your release from the Hospital before
returning home, You may be eligible for an additional benefit of
seventy–five ($75.00) dollars per day for up to a maximum of
five (5) days towards the cost of a hotel room.
You are eligible if Your name is embossed on an elig
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Picasso
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Re: Health Insurance Out of Network ruling issue

Post by Picasso »

investorpeter wrote: Tue Jun 14, 2022 2:30 pm
Picasso wrote: Tue Jun 14, 2022 12:23 am
Artful Dodger wrote: Mon Jun 13, 2022 12:47 pm Full disclosure- I work in the health insurance/ employee benefits area.

Your emergency was on Thursday when the accident occurred. The follow up surgery on Tuesday would not be considered emergency care unless your extended policy specifically included follow up care. You did have two business days to call your insurance company after the accident to ask how services would be covered. I’m also a little surprised the provider didn’t do some type of benefit check prior to the surgery being scheduled.

I think you have a shot at getting it paid, but you’re going to have to work with the company and with the providers. A lot of the time, insurers will have back up participation in a national PPO network which could help. If the providers (surgeon, anesthesiologist, other docs, and hospital or clinic) are willing to negotiate with the insurance company so the cost is comparable to what they would see in network, that’s your best hope.
Another health insurance management role here. This is correct.

No Surprises Act only applies to emergency care and the subsequent surgery is not considered emergency care.

Hospital prob only did eligibility check and no OON digging. Standard I think.

I’m sorry this happened to you, but you bought a less expensive plan and happened to have an accident where your plan has leaner coverage. Maybe consider a more comprehensive plan in the future.
I'm genuinely curious because this is a scenario I worry about while traveling. If OP did contact the insurer and was informed that the surgery would be considered out-of-network, what option would they have for obtaining the surgery in-network? To travel back home against medical advice?

For many, there is no option to obtain any meaningful out-of-network coverage, at any cost.
I think you are seeing this clearly. The story here is that as healthcare costs have gone up, up, up over the years and pushed premiums upwards, there is greater market demand for insurance products that are comparatively lower in premium payments or even level YoY (particularly in the individual ACA market). The way that insurers do this is by - you guessed it - reducing benefits, mostly through higher cost shares (deductible/copay/coins), increased specialty and Rx tiering, and removing lesser used benefits like OON coverage. For those who travel I would really suggest going with a national carrier or Blues plan and don’t choose the narrower networks.

Just like auto, home, renters, term life insurance etc, you are paying to hedge against risk and you really do get what you pay for.
investorpeter
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Re: Health Insurance Out of Network ruling issue

Post by investorpeter »

ResearchMed wrote: Tue Jun 14, 2022 9:23 pm
investorpeter wrote: Tue Jun 14, 2022 2:30 pm I'm genuinely curious because this is a scenario I worry about while traveling. If OP did contact the insurer and was informed that the surgery would be considered out-of-network, what option would they have for obtaining the surgery in-network? To travel back home against medical advice?

For many, there is no option to obtain any meaningful out-of-network coverage, at any cost.
[emphasis added]


"while traveling..." there is travel insurance.

We always get that when out of the country, but the coverage we get would also include travel within the USA.

There are quite a few different types of policies; many include insuring the costs of the travel itself, such as non-refundable cruise or resort expenses along with medical coverage.
And for the medical coverage, there are many different limits available, as well as restrictions, so pay attention to the small print.

Better yet, contact a travel insurance agent or broker (someone who deals with several different travel insurers). They can help one get the best possible coverage given one's concerns.
To have the best choice of coverages, it's important to start the coverage within 10-20 days of the FIRST payment (even if it is a refundable deposit; one only needs to insure the deposit and add coverage as more payments are made). The amount of time varies with the policy and the state of residence (USA-resident based coverage).
One important type of coverage to pay attention to are policies with restrictions about "pre-existing conditions". This is defined differently than we typically think about it in everyday life.
And pay attention to the policy limits for medical coverage. It varies considerably.

Travel insurance for medical coverage typically has nothing to do with "in network" or not. It just pays the costs, as long as it's not excluded and doesn't exceed the coverage maximum.

The types of policies we get also include coverage for losses of the travel costs as well as medical costs, but there are policies that focus on the medical care.

We use www.TripInsuranceStore.com and others here on BH also have had good experiences with them.

In our case, we have had quite a few claims (unfortunately), including some large claims. All have been paid without any nonsense.

Whether one wants to have this extra coverage is a personal choice, obviously. However, it's not the case that "...there is no option to obtain any meaningful out-of-network coverage, at any cost."
And it doesn't even need to be expensive, although cost would vary by situation.

RM
I was referring to healthcare insurance coverage, specifically ACA exchange plans. Out-of-network coverage beyond emergency care seems to be extremely rare for ACA plans. I have yet to see one. At least OP had an out-of-pocket max for out-of-network care. For all ACA plans I have seen, the insured would have been facing a potentially exorbitant hospital bill at “rack rates” or traveling home with a broken, deformed ankle against the advice of the orthopedic surgeon. If the surgeon stated in writing that OPs wife should not travel, I would think there is a strong argument to make that the subsequent surgery should have been considered under the same incident. I guess the lesson learned is to hash these things out with the insurance company before the surgery occurs, if at all possible.
investorpeter
Posts: 599
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Re: Health Insurance Out of Network ruling issue

Post by investorpeter »

Picasso wrote: Tue Jun 14, 2022 11:06 pm
investorpeter wrote: Tue Jun 14, 2022 2:30 pm
Picasso wrote: Tue Jun 14, 2022 12:23 am
Artful Dodger wrote: Mon Jun 13, 2022 12:47 pm Full disclosure- I work in the health insurance/ employee benefits area.

Your emergency was on Thursday when the accident occurred. The follow up surgery on Tuesday would not be considered emergency care unless your extended policy specifically included follow up care. You did have two business days to call your insurance company after the accident to ask how services would be covered. I’m also a little surprised the provider didn’t do some type of benefit check prior to the surgery being scheduled.

I think you have a shot at getting it paid, but you’re going to have to work with the company and with the providers. A lot of the time, insurers will have back up participation in a national PPO network which could help. If the providers (surgeon, anesthesiologist, other docs, and hospital or clinic) are willing to negotiate with the insurance company so the cost is comparable to what they would see in network, that’s your best hope.
Another health insurance management role here. This is correct.

No Surprises Act only applies to emergency care and the subsequent surgery is not considered emergency care.

Hospital prob only did eligibility check and no OON digging. Standard I think.

I’m sorry this happened to you, but you bought a less expensive plan and happened to have an accident where your plan has leaner coverage. Maybe consider a more comprehensive plan in the future.
I'm genuinely curious because this is a scenario I worry about while traveling. If OP did contact the insurer and was informed that the surgery would be considered out-of-network, what option would they have for obtaining the surgery in-network? To travel back home against medical advice?

For many, there is no option to obtain any meaningful out-of-network coverage, at any cost.
I think you are seeing this clearly. The story here is that as healthcare costs have gone up, up, up over the years and pushed premiums upwards, there is greater market demand for insurance products that are comparatively lower in premium payments or even level YoY (particularly in the individual ACA market). The way that insurers do this is by - you guessed it - reducing benefits, mostly through higher cost shares (deductible/copay/coins), increased specialty and Rx tiering, and removing lesser used benefits like OON coverage. For those who travel I would really suggest going with a national carrier or Blues plan and don’t choose the narrower networks.

Just like auto, home, renters, term life insurance etc, you are paying to hedge against risk and you really do get what you pay for.
Thanks for the insider perspective. The challenge I have with the health insurance marketplace (both ACA and private individual plans) is that it is so hard to figure out what will and will not be covered before a situation occurs because every situation is unique. And the rules are Byzantine. If the OPs wife had been admitted to the hospital after the fracture and then the surgery occurred a few days later, I assume it would have been considered the same incident? So from the insurer’s point of view, the emergency ends after discharge?
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Picasso
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Re: Health Insurance Out of Network ruling issue

Post by Picasso »

investorpeter wrote: Tue Jun 14, 2022 11:26 pm
Picasso wrote: Tue Jun 14, 2022 11:06 pm
investorpeter wrote: Tue Jun 14, 2022 2:30 pm
Picasso wrote: Tue Jun 14, 2022 12:23 am
Artful Dodger wrote: Mon Jun 13, 2022 12:47 pm Full disclosure- I work in the health insurance/ employee benefits area.

Your emergency was on Thursday when the accident occurred. The follow up surgery on Tuesday would not be considered emergency care unless your extended policy specifically included follow up care. You did have two business days to call your insurance company after the accident to ask how services would be covered. I’m also a little surprised the provider didn’t do some type of benefit check prior to the surgery being scheduled.

I think you have a shot at getting it paid, but you’re going to have to work with the company and with the providers. A lot of the time, insurers will have back up participation in a national PPO network which could help. If the providers (surgeon, anesthesiologist, other docs, and hospital or clinic) are willing to negotiate with the insurance company so the cost is comparable to what they would see in network, that’s your best hope.
Another health insurance management role here. This is correct.

No Surprises Act only applies to emergency care and the subsequent surgery is not considered emergency care.

Hospital prob only did eligibility check and no OON digging. Standard I think.

I’m sorry this happened to you, but you bought a less expensive plan and happened to have an accident where your plan has leaner coverage. Maybe consider a more comprehensive plan in the future.
I'm genuinely curious because this is a scenario I worry about while traveling. If OP did contact the insurer and was informed that the surgery would be considered out-of-network, what option would they have for obtaining the surgery in-network? To travel back home against medical advice?

For many, there is no option to obtain any meaningful out-of-network coverage, at any cost.
I think you are seeing this clearly. The story here is that as healthcare costs have gone up, up, up over the years and pushed premiums upwards, there is greater market demand for insurance products that are comparatively lower in premium payments or even level YoY (particularly in the individual ACA market). The way that insurers do this is by - you guessed it - reducing benefits, mostly through higher cost shares (deductible/copay/coins), increased specialty and Rx tiering, and removing lesser used benefits like OON coverage. For those who travel I would really suggest going with a national carrier or Blues plan and don’t choose the narrower networks.

Just like auto, home, renters, term life insurance etc, you are paying to hedge against risk and you really do get what you pay for.
Thanks for the insider perspective. The challenge I have with the health insurance marketplace (both ACA and private individual plans) is that it is so hard to figure out what will and will not be covered before a situation occurs because every situation is unique. And the rules are Byzantine. If the OPs wife had been admitted to the hospital after the fracture and then the surgery occurred a few days later, I assume it would have been considered the same incident? So from the insurer’s point of view, the emergency ends after discharge?
You are not wrong - it’s very confusing and I doubt many people shopping on the ACA exchange are reading all the fine print on plans that are hundreds more per month than the cheapest option. It’s not a good system, but it’s our system and it’s made a lot of doctors and administrators rich.
Northern Flicker
Posts: 15159
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Re: Health Insurance Out of Network ruling issue

Post by Northern Flicker »

investorpeter wrote: I was referring to healthcare insurance coverage, specifically ACA exchange plans. Out-of-network coverage beyond emergency care seems to be extremely rare for ACA plans.
It depends on the state. Where I live there initially were a number of PPOs with national networks on the exchange. That is now down to one insurer offering them, but it is still available. If you are outside the handful of states where this insurer offers plans, the network is narrow, and may not include the providers you would prefer, but for plans offered by this insurer, there is at least 1 hospital and at least 1 urgent care clinic in-network in most or all communities that have such a facility.
Northern Flicker
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Re: Health Insurance Out of Network ruling issue

Post by Northern Flicker »

investorpeter wrote: If the OPs wife had been admitted to the hospital after the fracture and then the surgery occurred a few days later, I assume it would have been considered the same incident? So from the insurer’s point of view, the emergency ends after discharge?
Yes. And if the patient can leave the hospital, maybe the patient can fly home? One benefit of travel insurance is that it may cover medical evacuation. I think in the OP’s case, there needed to be communication between the insurer, the insured, and the physician treating the injury to establish the medically feasible options.
investorpeter
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Re: Health Insurance Out of Network ruling issue

Post by investorpeter »

Northern Flicker wrote: Wed Jun 15, 2022 12:39 am
investorpeter wrote: I was referring to healthcare insurance coverage, specifically ACA exchange plans. Out-of-network coverage beyond emergency care seems to be extremely rare for ACA plans.
It depends on the state. Where I live there initially were a number of PPOs with national networks on the exchange. That is now down to one insurer offering them, but it is still available. If you are outside the handful of states where this insurer offers plans, the network is narrow, and may not include the providers you would prefer, but for plans offered by this insurer, there is at least 1 hospital and at least 1 urgent care clinic in-network in most or all communities that have such a facility.
One more question, if you don’t mind, to help me evaluate the ACA plans available to me, with regard to out-of-network benefits. I apologize to OP for hijacking this thread.

In my state ACA exchange, there is only one insurance provider that offers any out-of-network benefits. It is a national provider with providers all over the US, but for the ACA plans, only the in-state providers are considered in-network, and the other out-of-state providers, even though they participate in plans offered by the same umbrella organization, are considered out-of-network. The out-of-network benefit has a 20k/40k individual/family deductible, after which health services are covered with up to 50% coinsurance for most services. Importantly, there is NO out-of-pocket max for out-of-network services.

So, with only a local network of in-network providers, a very high out-of-network deductible and no out-of-pocket max, the out-of-network benefits seem almost negligible, and I did not seriously consider this plan. The only tangible benefit is the 50% coinsurance, which is nice, but without an out-of-pocket max, I am still at risk of potentially devastating, bankruptcy-inducing medical bills.

But after thinking about it some more, it seems there could be one other major benefit, which is that since this insurance company has existing relationships with providers around the country, and since they would have to pay for the other 50% of the bill, it is likely that they have negotiated significant discounts with the out-of-(my)-network providers so that the out-of-network charges would be closer to the usual and customary in-network charges, rather than the rack rate of the facility. So it is possible that I would be paying 50% coinsurance on a significantly lower charge, compared to what I would be charged for out-of-network services if I had insurance through a provider that had no relationship whatsoever with that particular provider. I’m not sure that benefit warrants the higher premiums, but I just want to be sure I’m looking at all the right angles. Seems the benefit of having the insurance company negotiate rates on my behalf for out-of-network services is the real significant benefit being offered here, as opposed to being left to fend for myself if I went with the other more local insurance plans. Does that seem correct?
jeam3131
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Re: Health Insurance Out of Network ruling issue

Post by jeam3131 »

Picasso wrote: Tue Jun 14, 2022 11:32 pm
investorpeter wrote: Tue Jun 14, 2022 11:26 pm
Picasso wrote: Tue Jun 14, 2022 11:06 pm
investorpeter wrote: Tue Jun 14, 2022 2:30 pm
Picasso wrote: Tue Jun 14, 2022 12:23 am

Another health insurance management role here. This is correct.

No Surprises Act only applies to emergency care and the subsequent surgery is not considered emergency care.

Hospital prob only did eligibility check and no OON digging. Standard I think.

I’m sorry this happened to you, but you bought a less expensive plan and happened to have an accident where your plan has leaner coverage. Maybe consider a more comprehensive plan in the future.
I'm genuinely curious because this is a scenario I worry about while traveling. If OP did contact the insurer and was informed that the surgery would be considered out-of-network, what option would they have for obtaining the surgery in-network? To travel back home against medical advice?

For many, there is no option to obtain any meaningful out-of-network coverage, at any cost.
I think you are seeing this clearly. The story here is that as healthcare costs have gone up, up, up over the years and pushed premiums upwards, there is greater market demand for insurance products that are comparatively lower in premium payments or even level YoY (particularly in the individual ACA market). The way that insurers do this is by - you guessed it - reducing benefits, mostly through higher cost shares (deductible/copay/coins), increased specialty and Rx tiering, and removing lesser used benefits like OON coverage. For those who travel I would really suggest going with a national carrier or Blues plan and don’t choose the narrower networks.

Just like auto, home, renters, term life insurance etc, you are paying to hedge against risk and you really do get what you pay for.
Thanks for the insider perspective. The challenge I have with the health insurance marketplace (both ACA and private individual plans) is that it is so hard to figure out what will and will not be covered before a situation occurs because every situation is unique. And the rules are Byzantine. If the OPs wife had been admitted to the hospital after the fracture and then the surgery occurred a few days later, I assume it would have been considered the same incident? So from the insurer’s point of view, the emergency ends after discharge?
You are not wrong - it’s very confusing and I doubt many people shopping on the ACA exchange are reading all the fine print on plans that are hundreds more per month than the cheapest option. It’s not a good system, but it’s our system and it’s made a lot of doctors and administrators rich.
It's made a lot of insurance companies rich.....those insurance premiums don't go to the hospital staff. The benefit of all the fine print and in network/out of network is to offload liability from the insurance company to the patient. This pads the pocket of the insurance company. The insurance company is also the one responsible for creating all the confusion, not the hospital. The insurance companies set all the rules and also are the one that get to enforce the rules. It's not hard to guess how that usually works out
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Picasso
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Re: Health Insurance Out of Network ruling issue

Post by Picasso »

jeam3131 wrote: Wed Jun 15, 2022 5:02 am
Picasso wrote: Tue Jun 14, 2022 11:32 pm
investorpeter wrote: Tue Jun 14, 2022 11:26 pm
Picasso wrote: Tue Jun 14, 2022 11:06 pm
investorpeter wrote: Tue Jun 14, 2022 2:30 pm

I'm genuinely curious because this is a scenario I worry about while traveling. If OP did contact the insurer and was informed that the surgery would be considered out-of-network, what option would they have for obtaining the surgery in-network? To travel back home against medical advice?

For many, there is no option to obtain any meaningful out-of-network coverage, at any cost.
I think you are seeing this clearly. The story here is that as healthcare costs have gone up, up, up over the years and pushed premiums upwards, there is greater market demand for insurance products that are comparatively lower in premium payments or even level YoY (particularly in the individual ACA market). The way that insurers do this is by - you guessed it - reducing benefits, mostly through higher cost shares (deductible/copay/coins), increased specialty and Rx tiering, and removing lesser used benefits like OON coverage. For those who travel I would really suggest going with a national carrier or Blues plan and don’t choose the narrower networks.

Just like auto, home, renters, term life insurance etc, you are paying to hedge against risk and you really do get what you pay for.
Thanks for the insider perspective. The challenge I have with the health insurance marketplace (both ACA and private individual plans) is that it is so hard to figure out what will and will not be covered before a situation occurs because every situation is unique. And the rules are Byzantine. If the OPs wife had been admitted to the hospital after the fracture and then the surgery occurred a few days later, I assume it would have been considered the same incident? So from the insurer’s point of view, the emergency ends after discharge?
You are not wrong - it’s very confusing and I doubt many people shopping on the ACA exchange are reading all the fine print on plans that are hundreds more per month than the cheapest option. It’s not a good system, but it’s our system and it’s made a lot of doctors and administrators rich.
It's made a lot of insurance companies rich.....those insurance premiums don't go to the hospital staff. The benefit of all the fine print and in network/out of network is to offload liability from the insurance company to the patient. This pads the pocket of the insurance company. The insurance company is also the one responsible for creating all the confusion, not the hospital. The insurance companies set all the rules and also are the one that get to enforce the rules. It's not hard to guess how that usually works out
I definitely understand your point, and it’s hard not to be frustrated at seeing profit numbers in the billions for insurance companies, but the situation is far more nuanced than this. The short of it is that consolidation in insurance has a few companies doing well, but there are tens of thousands of hospitals, clinics and centers all making large profits that result in much more combined wealth than these few number of conglomerates. Insurance company spending is also capped by regulation, with resulting margins around 2%. All the money goes to, in descending order: inpatient hospital stays > provider fees > pharmaceuticals.
jeam3131
Posts: 262
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Re: Health Insurance Out of Network ruling issue

Post by jeam3131 »

Picasso wrote: Wed Jun 15, 2022 6:30 am
jeam3131 wrote: Wed Jun 15, 2022 5:02 am
Picasso wrote: Tue Jun 14, 2022 11:32 pm
investorpeter wrote: Tue Jun 14, 2022 11:26 pm
Picasso wrote: Tue Jun 14, 2022 11:06 pm

I think you are seeing this clearly. The story here is that as healthcare costs have gone up, up, up over the years and pushed premiums upwards, there is greater market demand for insurance products that are comparatively lower in premium payments or even level YoY (particularly in the individual ACA market). The way that insurers do this is by - you guessed it - reducing benefits, mostly through higher cost shares (deductible/copay/coins), increased specialty and Rx tiering, and removing lesser used benefits like OON coverage. For those who travel I would really suggest going with a national carrier or Blues plan and don’t choose the narrower networks.

Just like auto, home, renters, term life insurance etc, you are paying to hedge against risk and you really do get what you pay for.
Thanks for the insider perspective. The challenge I have with the health insurance marketplace (both ACA and private individual plans) is that it is so hard to figure out what will and will not be covered before a situation occurs because every situation is unique. And the rules are Byzantine. If the OPs wife had been admitted to the hospital after the fracture and then the surgery occurred a few days later, I assume it would have been considered the same incident? So from the insurer’s point of view, the emergency ends after discharge?
You are not wrong - it’s very confusing and I doubt many people shopping on the ACA exchange are reading all the fine print on plans that are hundreds more per month than the cheapest option. It’s not a good system, but it’s our system and it’s made a lot of doctors and administrators rich.
It's made a lot of insurance companies rich.....those insurance premiums don't go to the hospital staff. The benefit of all the fine print and in network/out of network is to offload liability from the insurance company to the patient. This pads the pocket of the insurance company. The insurance company is also the one responsible for creating all the confusion, not the hospital. The insurance companies set all the rules and also are the one that get to enforce the rules. It's not hard to guess how that usually works out
I definitely understand your point, and it’s hard not to be frustrated at seeing profit numbers in the billions for insurance companies, but the situation is far more nuanced than this. The short of it is that consolidation in insurance has a few companies doing well, but there are tens of thousands of hospitals, clinics and centers all making large profits that result in much more combined wealth than these few number of conglomerates. Insurance company spending is also capped by regulation, with margins around 2%. All the money goes to, in descending order: inpatient hospital stays > provider fees > pharmaceuticals.
It's not about "seeing profits" and then having a knee jerk reaction about who to point a finger at. At the end of the day, problems like the OP are having are purely made because of insurance companies. As I said, they make and enforce the rules. They also set all the fee schedules. They dictate how much the hospital is allowed to charge for any given service and who's responsible for paying. Your doctor has absolutely nothing to do with it. They don't have any control or say over the billing or how it's processed. They're just there to provide the patient care.
clip651
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Re: Health Insurance Out of Network ruling issue

Post by clip651 »

Battleborn33 wrote: Sun Jun 12, 2022 5:28 pm
I plan to appeal the decision of the surgery and follow up care being out of network. I hoping to find someone with experience with a similar situation who could provide some insight and guidance as to why most of her care is being considered out of network and what I might do to increase our chances of a successful appeal.

ON another topic, it's now 3 months since her accident and surgery and we have received a single invoice, it's from the anesthesiologist, no others. We fortunately have very little experience with the health care system, but is this normal? I see the claims that were sent to the insurance company, that's how I know how Select Health coded them, but no invoices from the providers yet.
I think a lot of the people posting in this thread have missed these details. The OP can see how the claims have been processed so far (out of network), but for the most part the OP has received no actual bills from providers.

I am not an expert by any means. But in my experience, this usually means the billing department is still going back and forth with the insurance company. I do not believe the OP needs to get involved in appeals at this stage (unless perhaps regarding that anesthesia bill if it is large and was processed as out of network). I believe the billing department is still going through their process. If more info is needed, I would start by checking in with the billing office to see if they are working to get the claims handled as an emergency/in network. But personally, I would stay out of it until actual bills arrive for OP. Let the billing department and insurance company figure out what they are doing first.

I have had EOBs (explanations of benefits) come through as denied, and yet no bill comes from the provider. The provider goes through their process, and later there is another EOB that shows what was allowed and paid by insurance, what my responsibility is, etc, and then at that point the provider's billing office sends a bill.

YMMV, but in my experience it doesn't pay (and isn't needed) to work on bills you haven't received yet. You don't know what agreement they will come to with insurance, nor what they will decide to actually bill you for yet.

cj
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galawdawg
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Re: Health Insurance Out of Network ruling issue

Post by galawdawg »

I agree that all of this angst and discussion of appeals and complaints to insurance regulators is likely premature based upon what OP has shared.

OP...have you actually received any Explanation of Benefits (EOB) on the claims relating to the injury? Until you receive those and the associated bills from the medical providers, I would recommend patience. Once you have received those and compared those with your insurance provider's summary of benefits and coverage and any other coverage documents, then if you believe the claim determinations are incorrect, you can appeal by following the procedure set forth by your insurance provider.

Best wishes...
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Picasso
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Re: Health Insurance Out of Network ruling issue

Post by Picasso »

jeam3131 wrote: Wed Jun 15, 2022 7:08 am
Picasso wrote: Wed Jun 15, 2022 6:30 am
jeam3131 wrote: Wed Jun 15, 2022 5:02 am
Picasso wrote: Tue Jun 14, 2022 11:32 pm
investorpeter wrote: Tue Jun 14, 2022 11:26 pm

Thanks for the insider perspective. The challenge I have with the health insurance marketplace (both ACA and private individual plans) is that it is so hard to figure out what will and will not be covered before a situation occurs because every situation is unique. And the rules are Byzantine. If the OPs wife had been admitted to the hospital after the fracture and then the surgery occurred a few days later, I assume it would have been considered the same incident? So from the insurer’s point of view, the emergency ends after discharge?
You are not wrong - it’s very confusing and I doubt many people shopping on the ACA exchange are reading all the fine print on plans that are hundreds more per month than the cheapest option. It’s not a good system, but it’s our system and it’s made a lot of doctors and administrators rich.
It's made a lot of insurance companies rich.....those insurance premiums don't go to the hospital staff. The benefit of all the fine print and in network/out of network is to offload liability from the insurance company to the patient. This pads the pocket of the insurance company. The insurance company is also the one responsible for creating all the confusion, not the hospital. The insurance companies set all the rules and also are the one that get to enforce the rules. It's not hard to guess how that usually works out
I definitely understand your point, and it’s hard not to be frustrated at seeing profit numbers in the billions for insurance companies, but the situation is far more nuanced than this. The short of it is that consolidation in insurance has a few companies doing well, but there are tens of thousands of hospitals, clinics and centers all making large profits that result in much more combined wealth than these few number of conglomerates. Insurance company spending is also capped by regulation, with margins around 2%. All the money goes to, in descending order: inpatient hospital stays > provider fees > pharmaceuticals.
It's not about "seeing profits" and then having a knee jerk reaction about who to point a finger at. At the end of the day, problems like the OP are having are purely made because of insurance companies. As I said, they make and enforce the rules. They also set all the fee schedules. They dictate how much the hospital is allowed to charge for any given service and who's responsible for paying. Your doctor has absolutely nothing to do with it. They don't have any control or say over the billing or how it's processed. They're just there to provide the patient care.
Ok. A vast oversimplification and misstatement of the rate contracting and network management process, regulation, and market dynamics, but this is not my hill (bill?) to die on.
jeam3131
Posts: 262
Joined: Sun Aug 26, 2018 2:48 pm

Re: Health Insurance Out of Network ruling issue

Post by jeam3131 »

Picasso wrote: Wed Jun 15, 2022 12:13 pm
jeam3131 wrote: Wed Jun 15, 2022 7:08 am
Picasso wrote: Wed Jun 15, 2022 6:30 am
jeam3131 wrote: Wed Jun 15, 2022 5:02 am
Picasso wrote: Tue Jun 14, 2022 11:32 pm

You are not wrong - it’s very confusing and I doubt many people shopping on the ACA exchange are reading all the fine print on plans that are hundreds more per month than the cheapest option. It’s not a good system, but it’s our system and it’s made a lot of doctors and administrators rich.
It's made a lot of insurance companies rich.....those insurance premiums don't go to the hospital staff. The benefit of all the fine print and in network/out of network is to offload liability from the insurance company to the patient. This pads the pocket of the insurance company. The insurance company is also the one responsible for creating all the confusion, not the hospital. The insurance companies set all the rules and also are the one that get to enforce the rules. It's not hard to guess how that usually works out
I definitely understand your point, and it’s hard not to be frustrated at seeing profit numbers in the billions for insurance companies, but the situation is far more nuanced than this. The short of it is that consolidation in insurance has a few companies doing well, but there are tens of thousands of hospitals, clinics and centers all making large profits that result in much more combined wealth than these few number of conglomerates. Insurance company spending is also capped by regulation, with margins around 2%. All the money goes to, in descending order: inpatient hospital stays > provider fees > pharmaceuticals.
It's not about "seeing profits" and then having a knee jerk reaction about who to point a finger at. At the end of the day, problems like the OP are having are purely made because of insurance companies. As I said, they make and enforce the rules. They also set all the fee schedules. They dictate how much the hospital is allowed to charge for any given service and who's responsible for paying. Your doctor has absolutely nothing to do with it. They don't have any control or say over the billing or how it's processed. They're just there to provide the patient care.
Ok. A vast oversimplification and misstatement of the rate contracting and network management process, regulation, and market dynamics, but this is not my hill (bill?) to die on.
i live and breathe in this space. It is of course simplified, but very accurate as well. The public perception of who to vilify and who has control over these issues is vastly misplaced. These misperceptions are also what caused some confusion with the OPs problems. Don't ask your doctor or nurse about insurance coverage. They aren't the ones dealing with that. And if they give you and information about coverage, don't rely on it. They have no ability to make or change those decisions.

If you are concerned about network issues, you need to call your insurance company and the hospital social work/financial team that should be available when you're there.
Northern Flicker
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Re: Health Insurance Out of Network ruling issue

Post by Northern Flicker »

investorpeter wrote: The out-of-network benefit has a 20k/40k individual/family deductible, after which health services are covered with up to 50% coinsurance for most services. Importantly, there is NO out-of-pocket max for out-of-network services.

So, with only a local network of in-network providers, a very high out-of-network deductible and no out-of-pocket max, the out-of-network benefits seem almost negligible, and I did not seriously consider this plan. The only tangible benefit is the 50% coinsurance, which is nice, but without an out-of-pocket max, I am still at risk of potentially devastating, bankruptcy-inducing medical bills.

But after thinking about it some more, it seems there could be one other major benefit, which is that since this insurance company has existing relationships with providers around the country, and since they would have to pay for the other 50% of the bill, it is likely that they have negotiated significant discounts with the out-of-(my)-network providers so that the out-of-network charges would be closer to the usual and customary in-network charges, rather than the rack rate of the facility.
I’m no health insurance expert, but I think it is highly unlikely that a hospital will have negotiated out-of-network rates with an insurer.

Your primary procedure is to ensure care is in-network even when traveling. This means only going to out-of-network hospitals for emergency care. The problem is that if you call an insurer to ask when in-network emergency care transitions to out-of-network non-emergency care, they may not provide an unambiguous answer. Whether one is taken to the hospital in an ambulance, and whether the hospital admission occurs from the emergency department may be inputs to the insurer’s determination.

Travel health insurance often covers up to $100K with a low deductible and includes medical evacuation benefits. This would combine with the PPO you describe to cover the first $180K. The idea is to cover to a point of traveling home.

If you could not travel normally, the medical evacuation benefit pays for essentially a flying ambulance. I have no experience with that, so not sure how that would work.

There also are hospital indemnity plans you could add to a health insurance plan. These pay a daily benefit after a 30-day elimination period, if say you were say hospitalized for 3 months from a serious accident. This seems like overkill.
Northern Flicker
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Re: Health Insurance Out of Network ruling issue

Post by Northern Flicker »

jeam3131 wrote: At the end of the day, problems like the OP are having are purely made because of insurance companies. As I said, they make and enforce the rules. They also set all the fee schedules. They dictate how much the hospital is allowed to charge for any given service and who's responsible for paying. Your doctor has absolutely nothing to do with it. They don't have any control or say over the billing or how it's processed. They're just there to provide the patient care.
Last I checked, providers voluntarily sign contracts with insurers to accept the negotiated rates. Both sides are a party to the setting of the in-network rates. On our individual exchange, some insurers have different plans that differ by which local hospital system is in-network. The premiums also vary, reflective of the different in-network fee schedules for each network. If the insurer were unilaterally forcing a fee schedule upon the hospitals, the premiums would not be varying.
jeam3131
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Re: Health Insurance Out of Network ruling issue

Post by jeam3131 »

Northern Flicker wrote: Wed Jun 15, 2022 1:24 pm
jeam3131 wrote: At the end of the day, problems like the OP are having are purely made because of insurance companies. As I said, they make and enforce the rules. They also set all the fee schedules. They dictate how much the hospital is allowed to charge for any given service and who's responsible for paying. Your doctor has absolutely nothing to do with it. They don't have any control or say over the billing or how it's processed. They're just there to provide the patient care.
Last I checked, providers voluntarily sign contracts with insurers to accept the negotiated rates. Both sides are a party to the setting of the in-network rates. On our individual exchange, some insurers have different plans that differ by which local hospital system is in-network. The premiums also vary, reflective of the different in-network fee schedules for each network. If the insurer were unilaterally forcing a fee schedule upon the hospitals, the premiums would not be varying.
Provider's (doctors, PAs, NPs) don't sign the insurance contracts, hospitals do. The person doing your surgery has no say whether the hospital is going to take your insurance or how much your insurance is going to reimburse the hospital for the procedure.

If you run your own office, then yes, the doctors running the office choose what contracts to sign, but in these situations, they pretty much have one option, accept the rates they give, or walk. Its next to impossible to negotiate. This is one of many reasons why independent doctors offices are becoming a thing of the past. Insurance companies don't care. Some insurances even charge an office fees to be in-network that exceed the amount the office would make by taking the insurance. This is one reason why many private offices are moving to a cash-pay model. Charge a lower set fee that is transparent and the patient is given a bill they can use to get reimbursement from their insurance company.
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ResearchMed
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Re: Health Insurance Out of Network ruling issue

Post by ResearchMed »

Northern Flicker wrote: Wed Jun 15, 2022 1:24 pm
jeam3131 wrote: At the end of the day, problems like the OP are having are purely made because of insurance companies. As I said, they make and enforce the rules. They also set all the fee schedules. They dictate how much the hospital is allowed to charge for any given service and who's responsible for paying. Your doctor has absolutely nothing to do with it. They don't have any control or say over the billing or how it's processed. They're just there to provide the patient care.
Last I checked, providers voluntarily sign contracts with insurers to accept the negotiated rates. Both sides are a party to the setting of the in-network rates. On our individual exchange, some insurers have different plans that differ by which local hospital system is in-network. The premiums also vary, reflective of the different in-network fee schedules for each network. If the insurer were unilaterally forcing a fee schedule upon the hospitals, the premiums would not be varying.

Isn't OP's problem due to providers who are *not* "in network"?

That problem is even worse because not only might there be lesser coverage for out-of-network (OON) coverage, but those non-network hospitals never needed to agree to anything at all.

So the OON insurance schedule may not match what the OON providers are demanding. Even the OON Out Of Pocket (OOP) Maximum is likely to be based upon something like "reasonable and customary". If an OON anesthesiologist bills $120k for helping out in a one hour surgery, that doesn't mean the insurer is going to pay everything above their listed OOP Max for the OON bills.
THAT can be a big part of the problem.

That "surprise" anesthesiologist scenario is usually something "in-network" with an OON provider showing up. I think that's what the new restrictions for surprise billing is for. I'm not aware (I could be wrong?) that the restrictions for surprise billings applies to out of network coverage. (Does it?)

RM
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Northern Flicker
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Re: Health Insurance Out of Network ruling issue

Post by Northern Flicker »

jeam3131 wrote: Provider's (doctors, PAs, NPs) don't sign the insurance contracts, hospitals do. The person doing your surgery has no say whether the hospital is going to take your insurance or how much your insurance is going to reimburse the hospital for the procedure.
That is not correct. Many if not most doctors working in hospitals are contractors with respect to the hospital. Their fee is billed separate from the hospital, and it is their contract with an insurer or lack thereof that determines the in-network status.

It is true that there is variance in who has the most leverage when insurance companies negotiate contracts. The recent balance billing law was in response to the fact that many ER docs are not part of any networks despite the hospitals in which they practice being in insurance networks. The patient has no control of the choice of ER doc when showing up in an ER, so the ER doc has leverage. On the other hand, a patient chooses their PCP, and normally chooses an in-network one, so that the insurers have more leverage in negotiating with PCPs.
jeam3131
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Re: Health Insurance Out of Network ruling issue

Post by jeam3131 »

Northern Flicker wrote: Wed Jun 15, 2022 2:56 pm
jeam3131 wrote: Provider's (doctors, PAs, NPs) don't sign the insurance contracts, hospitals do. The person doing your surgery has no say whether the hospital is going to take your insurance or how much your insurance is going to reimburse the hospital for the procedure.
That is not correct. Many if not most doctors working in hospitals are contractors with respect to the hospital. Their fee is billed separate from the hospital, and it is their contract with an insurer or lack thereof that determines the in-network status.

It is true that there is variance in who has the most leverage when insurance companies negotiate contracts. The recent balance billing law was in response to the fact that many ER docs are not part of any networks despite the hospitals in which they practice being in insurance networks. The patient has no control of the choice of ER doc when showing up in an ER, so the ER doc has leverage. On the other hand, a patient chooses their PCP, and normally chooses an in-network one, so that the insurers have more leverage in negotiating with PCPs.
Not correct. It totally depends. If the doctor is employed by the hospital, then the doctor doesn't sign insurance contracts. If the doctor is not employed by the hospital, they are almost always part of some external group that signs the contracts. These groups usually consist of many doctors across many different hospitals. Many of the external groups are now private equity backed. They bought up ER, anesthesia docs etc and handle all insurance negotiations. Individual doctors don't just work for a hospital as an independent contractor. That's pretty uncommon.

I guess the overall message is that the individual doc in the ER or the one providing the anesthesia has very little to do with your insurance contract, network status etc. That's all dealt with by people above (whether that's hospital admin, private equity, large physician groups etc). And one of the main reasons why insurance are out of network is because they're likely terrible to work with. Some deny claims for no valid reason, play games, cheat, reimburse less than the cost it takes to provide care etc. I was part of a situation where an insurance company claimed an in network provider was out of network when bills were submitted, and they would subsequently deny payment of the claims saying they were out of network. The state insurance regulation had to get involved and force them to pay. It took almost a year to get that sorted out. They know most places will just give up. That's the level these insurance companies will go to
Last edited by jeam3131 on Wed Jun 15, 2022 3:54 pm, edited 1 time in total.
california_folks
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Re: Health Insurance Out of Network ruling issue

Post by california_folks »

I hope for the best resolution for OP, however I am totally lost on what is the best recommendation for traveling within US while having medical insurance and facing emergency.
From our experience, having phone calls to the insurance call center even without emergency it was never conclusive.
Also, we found out, that for example a pathology lab and anthologists are usually not in any network and may bill separately.
How do we protect ourselves from such situation?
Do you suggest having travel insurance on top of medical even within US for emergencies?
Some of travel insurances say they are secondary, does it matter?
So confusing... :| :| :|
Last edited by california_folks on Wed Jun 15, 2022 4:17 pm, edited 1 time in total.
jeam3131
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Re: Health Insurance Out of Network ruling issue

Post by jeam3131 »

california_folks wrote: Wed Jun 15, 2022 3:34 pm I hope for the best resolution for OP, however I am totally lost on what is the best recommendation for traveling within US while having medical insurance and facing emergency.
From our experience, having phone calls to the insurance call center even without emergency never got a clear confirmations on anything.
Also, we found out, that for example a pathology lab and anthologists are usually not in any network and may bill separately.
How do we protect ourselves from such situation?
Do you suggest having travel insurance on top of medical even within US for emergencies?
Some of travel insurances say they are secondary, does it matter?
So confusing... :| :| :|
That's a great question. I would say start by reading the section in your summary plan description or evidence of coverage booklet. It should describe what your insurance company expects regarding notifying them of emergency care.
california_folks
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Re: Health Insurance Out of Network ruling issue

Post by california_folks »

jeam3131 wrote: Wed Jun 15, 2022 4:03 pm
california_folks wrote: Wed Jun 15, 2022 3:34 pm I hope for the best resolution for OP, however I am totally lost on what is the best recommendation for traveling within US while having medical insurance and facing emergency.
From our experience, having phone calls to the insurance call center even without emergency never got a clear confirmations on anything.
Also, we found out, that for example a pathology lab and anthologists are usually not in any network and may bill separately.
How do we protect ourselves from such situation?
Do you suggest having travel insurance on top of medical even within US for emergencies?
Some of travel insurances say they are secondary, does it matter?
So confusing... :| :| :|
That's a great question. I would say start by reading the section in your summary plan description or evidence of coverage booklet. It should describe what your insurance company expects regarding notifying them of emergency care.
Something like that ?
https://healthy.kaiserpermanente.org/co ... -ca-en.pdf
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