Heading to ER, surprise bills [update: home again]

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sawhorse
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Heading to ER, surprise bills [update: home again]

Post by sawhorse » Mon Oct 23, 2017 5:48 pm

I'm heading to the ER on the recommendation of the urgent care center.

I'm worried about surprise bills. What can I do to avoid them? I'm going to an in-network hospital, but I'm afraid of getting a bill from an out of network provider.

I'm not taking an ambulance, so that's not an issue.
Last edited by sawhorse on Tue Oct 24, 2017 5:49 am, edited 1 time in total.

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Sandtrap
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Post by Sandtrap » Mon Oct 23, 2017 5:53 pm

Sorry to hear that your health is compromised.
A recent ER visit cost me nearly $6k. Yikes
Just be sure to have a copy of all the documents involved, and as you go along, copies of billings and medical records to set things straight with the insurance company later on.

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Re: Urgent! Heading to ER, surprise bills

Post by acunn » Mon Oct 23, 2017 6:00 pm

I hope you get the care you need quickly. It seems like you could ask if the provider is in network but if they said no would you leave? If you have an emergency then the care is necessary in or out of network. Best wishes!

sawhorse
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Re: Urgent! Heading to ER, surprise bills

Post by sawhorse » Mon Oct 23, 2017 6:05 pm

acunn wrote:
Mon Oct 23, 2017 6:00 pm
I hope you get the care you need quickly. It seems like you could ask if the provider is in network but if they said no would you leave? If you have an emergency then the care is necessary in or out of network. Best wishes!
I feel okay (I've gone blind in one eye suddenly but am not in pain) so maybe I can wait for an in network provider? But what if there aren't any on that shift?

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samsoes
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Re: Urgent! Heading to ER, surprise bills

Post by samsoes » Mon Oct 23, 2017 6:08 pm

Put the computer/phone/device down, shut it off, and focus on your health. :!: Please don't delay any evaluation or treatment because of network membership concerns, please!
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Re: Urgent! Heading to ER, surprise bills

Post by Kenkat » Mon Oct 23, 2017 6:15 pm

Sorry to hear about your health issue; take care of yourself.

At the beginning of the year, I had the pleasure of going to the doctor, then to the satellite ER and finally an ambulance ride to the hospital in the space of about 5 hours. I was in the hospital for 2 days (pulmonary embolism) and although I didn’t really give it much thought at the time, everything was in network and covered in full after my deductible. I think if you stick to the major providers in town, you likely won’t have any issues. I did go to the facilities recommended by my physician who has always done a good job of being conscious of the cost of care.

The ER staff did get a good laugh when I asked whether I should drive myself to the hospital or ask my wife to pick me up and take me.

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Re: Urgent! Heading to ER, surprise bills

Post by camillus » Mon Oct 23, 2017 6:18 pm

There are very few things worth more than your sight. If someone I loved went blind in one eye and went to an urgent care center instead of the best ER in town, I would be extremely upset with them.

Put a value on your sight. A million? 10 million? Your condition could also indicate a problem with your brain, like having a stroke - time is of the essence.

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Re: Urgent! Heading to ER, surprise bills

Post by student » Mon Oct 23, 2017 6:20 pm

Sorry to hear this. Best wishes. I will bite my tongue and not comment on the health system here. Please follow the advice.
samsoes wrote:
Mon Oct 23, 2017 6:08 pm
Put the computer/phone/device down, shut it off, and focus on your health. :!: Please don't delay any evaluation or treatment because of network membership concerns, please!
I hope you have someone to drive you to the ER.

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Re: Urgent! Heading to ER, surprise bills

Post by Teague » Mon Oct 23, 2017 6:54 pm

Right off the bat I can think of two potential causes for your problem that are true emergencies that can become permanent if not attended to quickly. Get to the ED now.
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climber2020
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Re: Urgent! Heading to ER, surprise bills

Post by climber2020 » Mon Oct 23, 2017 6:56 pm

sawhorse wrote:
Mon Oct 23, 2017 6:05 pm
acunn wrote:
Mon Oct 23, 2017 6:00 pm
I hope you get the care you need quickly. It seems like you could ask if the provider is in network but if they said no would you leave? If you have an emergency then the care is necessary in or out of network. Best wishes!
I feel okay (I've gone blind in one eye suddenly but am not in pain) so maybe I can wait for an in network provider? But what if there aren't any on that shift?
Make sure you go to an ER that has an ophthalmologist on call. An ER physician will not be able to do anything for you except either consult an ophthalmologist or refer you to a hospital that has an ophthalmologist.

NotWhoYouThink
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Re: Urgent! Heading to ER, surprise bills

Post by NotWhoYouThink » Mon Oct 23, 2017 6:58 pm

The time to have thought about this was before you needed care.

The next time to research it is after you have dealt with your current situation.

In the middle of the emergency is not the time to do this research.

Katietsu
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Re: Urgent! Heading to ER, surprise bills

Post by Katietsu » Mon Oct 23, 2017 7:25 pm

ACA dictates that care must be provided at in network co pays/deductibles for emergency situations. This is clearly an emergency. If the ophthalmologist on call determines the situation requires non emergency care that is when you need to start worrying about bills and networks.

sawhorse
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Re: Urgent! Heading to ER, surprise bills

Post by sawhorse » Mon Oct 23, 2017 8:30 pm

Katietsu wrote:
Mon Oct 23, 2017 7:25 pm
ACA dictates that care must be provided at in network co pays/deductibles for emergency situations. This is clearly an emergency. If the ophthalmologist on call determines the situation requires non emergency care that is when you need to start worrying about bills and networks.
According to this article, that's not true.

https://nyti.ms/2tDFLQk

Anyway, I'm in the waiting room.

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Re: Urgent! Heading to ER, surprise bills

Post by White Coat Investor » Mon Oct 23, 2017 8:37 pm

sawhorse wrote:
Mon Oct 23, 2017 5:48 pm
I'm heading to the ER on the recommendation of the urgent care center.

I'm worried about surprise bills. What can I do to avoid them? I'm going to an in-network hospital, but I'm afraid of getting a bill from an out of network provider.

I'm not taking an ambulance, so that's not an issue.
I hope everything turns out okay, but I confess I've got to wonder how much of an emergency it is when you can stop and post on Bogleheads en route!
1) Invest you must 2) Time is your friend 3) Impulse is your enemy | 4) Basic arithmetic works 5) Stick to simplicity 6) Stay the course

staythecourse
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Re: Urgent! Heading to ER, surprise bills

Post by staythecourse » Mon Oct 23, 2017 8:38 pm

Katietsu wrote:
Mon Oct 23, 2017 7:25 pm
ACA dictates that care must be provided at in network co pays/deductibles for emergency situations. This is clearly an emergency. If the ophthalmologist on call determines the situation requires non emergency care that is when you need to start worrying about bills and networks.
I am too lazy to look it up, but that sounds completely wrong. If EVERY emergency has to be covered by an in network physician that mean EVERY ER doctor in the country is in network for every insurance company. So that means there are no ER doctors out of network?

In reality, there is not much you can do. There are only so many people on call if consult is called when in the ER so you don't have much choice. Anything that can be elective as out patient decline it in the ER and just do it as an out patient.

Good luck.
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White Coat Investor
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Re: Urgent! Heading to ER, surprise bills

Post by White Coat Investor » Mon Oct 23, 2017 8:40 pm

sawhorse wrote:
Mon Oct 23, 2017 8:30 pm
Anyway, I'm in the waiting room.
This is like a real time ER visit. Loving it! Make sure you post during every time you get results! And ask the doc if he/she knows me!

At any rate, if you really want to keep costs down, just let the doc know upfront you'd like to minimize costs in any safe way possible. Lots of care is optional. Most patients don't want to talk about cost. It's sometimes refreshing to do so. It also helps if you remind the doc several times that you're not going to sue him/her, and that you're willing to not have 100% reassurance that you don't have something today and will come back if you're getting worse. Just ask if he/she would have done what they're discussing with you if they were in your shoes. That'll reduce costs more than anything.
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Re: Urgent! Heading to ER, surprise bills

Post by Katietsu » Mon Oct 23, 2017 8:44 pm

Maybe someone else can talk to real world applications. I know that there are visits to an emergency room that are not actually emergencies. (Just last week I encountered someone who went to the ER for a problem. When asked how long they had been experiencing symptoms, the answer was 2.5 months.) Also, if you have a high deductible plan, I would guess that your care choices could affect your out of pocket.

However, please see the information below from healthcare.gov


From Healthcare.gov:

Out-of-network emergency care is covered under all insurance plans sold after March 23rd, 2010 as part of Ten Essential Benefits under the Affordable Care Act.

Insurance plans can't require higher copayments or coinsurance if you get emergency care out-of-network and they cannot require prior approval either. All non-emergency care must be done in-network to be covered and may require prior approval.

If your insurer is trying to bill you for the care you may have to appeal their decision.

Grandfathered plans bought before March 23, 2010 may not follow this same rule. Short term health insurance and some other coverage types may also not follow this rule.

If you get any care that is not strictly emergency care, out-of-network rates may apply. So always be very careful with this and make sure you are communicating with your insurance provider so you don't get blindsided by extra costs. Some plans will have a separate out-of-pocket maximum and deductible, so keep that in mind too.
Last edited by Katietsu on Mon Oct 23, 2017 8:58 pm, edited 3 times in total.

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Re: Urgent! Heading to ER, surprise bills

Post by White Coat Investor » Mon Oct 23, 2017 8:46 pm

sawhorse wrote:
Mon Oct 23, 2017 6:05 pm
acunn wrote:
Mon Oct 23, 2017 6:00 pm
I hope you get the care you need quickly. It seems like you could ask if the provider is in network but if they said no would you leave? If you have an emergency then the care is necessary in or out of network. Best wishes!
I feel okay (I've gone blind in one eye suddenly but am not in pain) so maybe I can wait for an in network provider? But what if there aren't any on that shift?
Oh, I just got down this far in the thread. That IS an emergency and you've done the right thing going in. Still doesn't mean you're going to get that sight back, but I'd quit worrying about the cost at this point. I'd do ANYTHING that could possibly restore sight in that eye. There are only a few things that cause painless, monocular vision loss and almost all of them are bad and many of them are not very reversible.

Be aware that many community EDs (including mine) don't have an ophthalmologist on call, and you're going to need one. If you have a University ED or other tertiary referral center, they're much more likely to have an ophthalmologist and save you a transfer.

And please tell me you're now out of the waiting room.
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Re: Urgent! Heading to ER, surprise bills

Post by avalpert » Mon Oct 23, 2017 8:47 pm

I wish I had good advice for you, I just want you to know I feel for the situation and hope it works out (preferably with nothing seriously wrong and no expensive consults needed to determine that).

I think the people who are telling you to not care about the potential cost and get whatever care is offered are demonstrating a tremendous lack of empathy - unless they are willing to pay the bills for you they really shouldn't be dismissing your financial concern.

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Re: Urgent! Heading to ER, surprise bills

Post by White Coat Investor » Mon Oct 23, 2017 8:55 pm

avalpert wrote:
Mon Oct 23, 2017 8:47 pm
I wish I had good advice for you, I just want you to know I feel for the situation and hope it works out (preferably with nothing seriously wrong and no expensive consults needed to determine that).

I think the people who are telling you to not care about the potential cost and get whatever care is offered are demonstrating a tremendous lack of empathy - unless they are willing to pay the bills for you they really shouldn't be dismissing your financial concern.
Seriously? The dude just went blind. What's your vision worth? Sure, the first eye might not be worth all that much, but I bet that second one is.

At any rate, this won't even be a very expensive visit I imagine. Maybe an MRI. Probably a consult. And a level 4 ED charge. Definitely worth paying cash for even if insurance covers nothing. The ED/hospital and emergency doc probably have an agreement with the insurance company (we have contracts with pretty much every one in our state). The radiologist (if needed) is probably in network. The ophthalmologist is the only one that may not be. But geez, it's his vision, not a cold or a sprained knee.
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Re: Urgent! Heading to ER, surprise bills

Post by sawhorse » Mon Oct 23, 2017 9:01 pm

White Coat Investor wrote:
Mon Oct 23, 2017 8:46 pm
sawhorse wrote:
Mon Oct 23, 2017 6:05 pm
acunn wrote:
Mon Oct 23, 2017 6:00 pm
I hope you get the care you need quickly. It seems like you could ask if the provider is in network but if they said no would you leave? If you have an emergency then the care is necessary in or out of network. Best wishes!
I feel okay (I've gone blind in one eye suddenly but am not in pain) so maybe I can wait for an in network provider? But what if there aren't any on that shift?
Oh, I just got down this far in the thread. That IS an emergency and you've done the right thing going in. Still doesn't mean you're going to get that sight back, but I'd quit worrying about the cost at this point. I'd do ANYTHING that could possibly restore sight in that eye. There are only a few things that cause painless, monocular vision loss and almost all of them are bad and many of them are not very reversible.

Be aware that many community EDs (including mine) don't have an ophthalmologist on call, and you're going to need one. If you have a University ED or other tertiary referral center, they're much more likely to have an ophthalmologist and save you a transfer.

And please tell me you're now out of the waiting room.
Sorry, I forgot to update about my symptoms. My vision came back on its own a short while ago!? The nurse said she still recommends getting seen by the doctor so here I am.
Last edited by sawhorse on Mon Oct 23, 2017 9:53 pm, edited 1 time in total.

staythecourse
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Re: Urgent! Heading to ER, surprise bills

Post by staythecourse » Mon Oct 23, 2017 9:21 pm

To the OP, glad to hear you are feeling better.

Good luck.
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Re: Urgent! Heading to ER, surprise bills

Post by Teague » Mon Oct 23, 2017 9:37 pm

OP maybe if you could update us once you have been diagnosed?

Best wishes, T.I.A. :wink: (thanks in advance)
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Re: Urgent! Heading to ER, surprise bills

Post by White Coat Investor » Mon Oct 23, 2017 9:52 pm

sawhorse wrote:
Mon Oct 23, 2017 9:01 pm
Sorry, I forgot to update about my symptoms. My vision came back on its own a short while ago!? The nurse said she still recommends getting seen by the doctor so here I am.
That's awesome! I'm so happy for you.
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Re: Urgent! Heading to ER, surprise bills

Post by Dendritic Tree » Mon Oct 23, 2017 9:55 pm

To take the thread back from medical issues involving a potential central retinal artery occlusion (if permanent, amaurosis fugax if temporary) - most insurance plans have some sort of in-network exemption for true emergency visits where even an out-of-network ER is covered at an in-network rate. So the moral is to focus on your health first and financial situations later.

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Re: Urgent! Heading to ER, surprise bills

Post by Dendritic Tree » Mon Oct 23, 2017 9:56 pm

Teague wrote:
Mon Oct 23, 2017 9:37 pm
OP maybe if you could update us once you have been diagnosed?

Best wishes, T.I.A. :wink: (thanks in advance)
“TIA” indeed. Of the eye.

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Re: Urgent! Heading to ER, surprise bills

Post by cashmoney » Mon Oct 23, 2017 10:01 pm

sawhorse wrote:
Mon Oct 23, 2017 5:48 pm
I'm heading to the ER on the recommendation of the urgent care center.

I'm worried about surprise bills. What can I do to avoid them? I'm going to an in-network hospital, but I'm afraid of getting a bill from an out of network provider.

I'm not taking an ambulance, so that's not an issue.

Your post reminded me of this classic Etrade commercial https://www.youtube.com/watch?v=oftjwYmlfoA

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Re: Urgent! Heading to ER, surprise bills

Post by toofache32 » Mon Oct 23, 2017 10:22 pm

Katietsu wrote:
Mon Oct 23, 2017 8:44 pm

From Healthcare.gov:

Out-of-network emergency care is covered under all insurance plans sold after March 23rd, 2010 as part of Ten Essential Benefits under the Affordable Care Act.

Insurance plans can't require higher copayments or coinsurance if you get emergency care out-of-network and they cannot require prior approval either. All non-emergency care must be done in-network to be covered and may require prior approval.

If your insurer is trying to bill you for the care you may have to appeal their decision.

Grandfathered plans bought before March 23, 2010 may not follow this same rule. Short term health insurance and some other coverage types may also not follow this rule.

If you get any care that is not strictly emergency care, out-of-network rates may apply. So always be very careful with this and make sure you are communicating with your insurance provider so you don't get blindsided by extra costs. Some plans will have a separate out-of-pocket maximum and deductible, so keep that in mind too.
This refers to insurance companies, not providers. In other words, out of network care that is "covered" does not mean paid in full. If they don't pay the entire bill then the remainder is on the patient. And it's an enormous fight to get the insurance company to pay. As a surgical subspecialist, I never ever got paid for OON emergency care which is one reason I stopped taking call in one of my hospitals. The ophthomologists stopped years ago for the same reason.

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Re: Urgent! Heading to ER, surprise bills

Post by toofache32 » Mon Oct 23, 2017 10:25 pm

acunn wrote:
Mon Oct 23, 2017 6:00 pm
I hope you get the care you need quickly. It seems like you could ask if the provider is in network but if they said no would you leave? If you have an emergency then the care is necessary in or out of network. Best wishes!
How would the provider know if he/she is in network with a given plan? When I was an in-network insurance doctor, I was on about 40 plans and their names all looked the same to me.

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Re: Urgent! Heading to ER, surprise bills

Post by Gnirk » Mon Oct 23, 2017 10:34 pm

Oops, read where you already visited the ER. Happy your vision came back. i had that happen once, but still had the MRI, which showed no issues, and I've been fine ever since. Hope yours turns out the same.
Last edited by Gnirk on Mon Oct 23, 2017 10:42 pm, edited 1 time in total.

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Re: Urgent! Heading to ER, surprise bills

Post by ResearchMed » Mon Oct 23, 2017 10:41 pm

sawhorse wrote:
Mon Oct 23, 2017 5:48 pm
I'm heading to the ER on the recommendation of the urgent care center.

I'm worried about surprise bills. What can I do to avoid them? I'm going to an in-network hospital, but I'm afraid of getting a bill from an out of network provider.

I'm not taking an ambulance, so that's not an issue.
Can OP please edit initial post here, so others know there is no longer any emergency?

Thanks.

RM
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Re: Urgent! Heading to ER, surprise bills

Post by BAM! » Mon Oct 23, 2017 10:50 pm

White Coat Investor wrote:
Mon Oct 23, 2017 8:55 pm
avalpert wrote:
Mon Oct 23, 2017 8:47 pm
I wish I had good advice for you, I just want you to know I feel for the situation and hope it works out (preferably with nothing seriously wrong and no expensive consults needed to determine that).

I think the people who are telling you to not care about the potential cost and get whatever care is offered are demonstrating a tremendous lack of empathy - unless they are willing to pay the bills for you they really shouldn't be dismissing your financial concern.
Seriously? The dude just went blind. What's your vision worth? Sure, the first eye might not be worth all that much, but I bet that second one is.

At any rate, this won't even be a very expensive visit I imagine. Maybe an MRI. Probably a consult. And a level 4 ED charge. Definitely worth paying cash for even if insurance covers nothing. The ED/hospital and emergency doc probably have an agreement with the insurance company (we have contracts with pretty much every one in our state). The radiologist (if needed) is probably in network. The ophthalmologist is the only one that may not be. But geez, it's his vision, not a cold or a sprained knee.
I'm suspecting you'll get a level 5 charge. Maybe even critical care time depending on specific details. These fees will pale in comparison to the facility fees the hospital charges.

Best of luck to your health and your pocketbook!

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Re: Urgent! Heading to ER, surprise bills

Post by sawhorse » Mon Oct 23, 2017 11:09 pm

Update. The ER doc ordered an MRI which I'm waiting for. Will the ER doc interpret the scan, or does a radiologist do that? If the latter, how do I know if the radiologist is in network since I might not even meet them?

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Re: Urgent! Heading to ER, surprise bills

Post by White Coat Investor » Mon Oct 23, 2017 11:10 pm

Radiologist. You won't. But he probably is.

Screwed up system isn't it?
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Re: Urgent! Heading to ER, surprise bills

Post by triceratop » Mon Oct 23, 2017 11:13 pm

I removed a number of off-topic posts. Please keep discussion on-topic to the OP's actionable concern: how to minimize costs and avoid surprise bills. Note also that medical advice is off-topic and such posts will be removed. A reminder about forum policy and unacceptable topics of discussion:
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In order to avoid the inevitable frictions that arise from these topics, political or religious posts and comments are prohibited.

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If readers can't do anything with the content of a topic other than argue about it, it does not belong here. Examples include:

* US or world economic, political, tax, health care and climate policies
see: rules
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Re: Urgent! Heading to ER, surprise bills

Post by Katietsu » Mon Oct 23, 2017 11:27 pm

toofache32 wrote:
Mon Oct 23, 2017 10:22 pm
Katietsu wrote:
Mon Oct 23, 2017 8:44 pm

From Healthcare.gov:

Out-of-network emergency care is covered under all insurance plans sold after March 23rd, 2010 as part of Ten Essential Benefits under the Affordable Care Act.

Insurance plans can't require higher copayments or coinsurance if you get emergency care out-of-network and they cannot require prior approval either. All non-emergency care must be done in-network to be covered and may require prior approval.

If your insurer is trying to bill you for the care you may have to appeal their decision.

Grandfathered plans bought before March 23, 2010 may not follow this same rule. Short term health insurance and some other coverage types may also not follow this rule.

If you get any care that is not strictly emergency care, out-of-network rates may apply. So always be very careful with this and make sure you are communicating with your insurance provider so you don't get blindsided by extra costs. Some plans will have a separate out-of-pocket maximum and deductible, so keep that in mind too.
This refers to insurance companies, not providers. In other words, out of network care that is "covered" does not mean paid in full. If they don't pay the entire bill then the remainder is on the patient. And it's an enormous fight to get the insurance company to pay. As a surgical subspecialist, I never ever got paid for OON emergency care which is one reason I stopped taking call in one of my hospitals. The ophthomologists stopped years ago for the same reason.
Thank you for the additional information. I did not realize balance billing following emergency care was still allowed in much of the country.

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Re: Urgent! Heading to ER, surprise bills

Post by carofe » Mon Oct 23, 2017 11:45 pm

Being in the hospital several times for the last two years, my recommendation is that you request to the hospital that you want to be seen by in-network providers only.
Sometimes the hospital assign to you an out-of-network provider without your knowledge and you may end up with pretty big bills.
The hospital will ask you to sign a paper that states that you are responsible for all expenses, even the out of network providers they assign to you.

That being said, I don't know how much of a control a hospital can have on the in/out of network problems when you visit facilities, honestly. In the worst case you can find a claim advocate at your HR that would fight the bills for you and may succeed in making the insurance company process the claims as in-network. You can also negotiate with the facility by telling them that you went there with the good faith of being a facility in network and you got an out of network provider.

I went myself thru that but thanks God our claim advocate from our HR fought and made the out of network claims go as in-network. The one we had to fight was a scheduled procedure, non-ER visit.

Anyway, it is kind of hard to be so cost aware when you are in the middle of a health issue. I hope my post helps you with ideas of what to do if you find bill surprises.
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Re: Urgent! Heading to ER, surprise bills

Post by MulesFan » Tue Oct 24, 2017 12:03 am

A year ago I fell & broke both wrists. Off to the ER, surgery & home to recover. A few weeks later, the bills started rolling in. I have a HDLP plan & paid bills except the anesthesiologist statement, which indicated it was with the insurance company being reviewed (billing told me not to pay yet). After receiving 3 or 4 statements they stopped coming, so I figured insurance had paid. Then this spring letters from debt collector started rolling in. Spoke with insurance agent & she started investigating. She found out the bill was coded as out of network (hospital/ER are in network). I spoke with collection agency & explained situation & they put a hold on contacting me. It was quiet for a while but a few weeks ago I got a letter from insurance company stating they paid about 10% of the bill & I still owe about $2,400. I’m working with insurance agent again to see if bill can get recoded but at this point it appears the anesthesiologist is able to bill as out of network even though it was in our local hospital. It certainly never occurred to me to ask him if he was going to bill me in network or out of network!

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munemaker
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Re: Urgent! Heading to ER, surprise bills

Post by munemaker » Tue Oct 24, 2017 3:20 am

MulesFan wrote:
Tue Oct 24, 2017 12:03 am
A year ago I fell & broke both wrists. Off to the ER, surgery & home to recover. A few weeks later, the bills started rolling in. I have a HDLP plan & paid bills except the anesthesiologist statement, which indicated it was with the insurance company being reviewed (billing told me not to pay yet). After receiving 3 or 4 statements they stopped coming, so I figured insurance had paid. Then this spring letters from debt collector started rolling in. Spoke with insurance agent & she started investigating. She found out the bill was coded as out of network (hospital/ER are in network). I spoke with collection agency & explained situation & they put a hold on contacting me. It was quiet for a while but a few weeks ago I got a letter from insurance company stating they paid about 10% of the bill & I still owe about $2,400. I’m working with insurance agent again to see if bill can get recoded but at this point it appears the anesthesiologist is able to bill as out of network even though it was in our local hospital. It certainly never occurred to me to ask him if he was going to bill me in network or out of network!
There is a term for this despicable practice: balance billing

HIinvestor
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Re: Urgent! Heading to ER, surprise bills

Post by HIinvestor » Tue Oct 24, 2017 3:43 am

I have successfully challenged an out of network pediatric anesthesiologist charge when we took S to an in network hospital and he had an in network provider who unbeknownst to us was using an out of network anesthesiologist.

I asked insurer how I was to know or question or change the anesthesiologist as I was never informed of consulted. After a bit of back and forth, the insurer agreed to pay provider as if they were in network and provider waived the rest of the balance.

Balance billing IS very unfair to patients, especially since we are not in a position to know which folks who provide our care are in or out of network, especially in an emergency or urgent situation. The cost difference can be VERay significant!

sawhorse
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Re: Urgent! Heading to ER, surprise bills

Post by sawhorse » Tue Oct 24, 2017 5:15 am

Update. I've been discharged. I've only been asked to pay the co-pay. Let's see if more bills come in.

I have a question regarding resident physicians. Both the ER physician and the radiologist during this visit are residents. I didn't see an opthamologist. I know residents are on salary - obscenely low ones at that. Does that mean that in/out of network doesn't apply to residents, so if the hospital is in network then so are the residents?

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Re: Urgent! Heading to ER, surprise bills

Post by gasman » Tue Oct 24, 2017 6:40 am

sawhorse wrote:
Tue Oct 24, 2017 5:15 am
Update. I've been discharged. I've only been asked to pay the co-pay. Let's see if more bills come in.

I have a question regarding resident physicians. Both the ER physician and the radiologist during this visit are residents. I didn't see an opthamologist. I know residents are on salary - obscenely low ones at that. Does that mean that in/out of network doesn't apply to residents, so if the hospital is in network then so are the residents?
Doubtful...The residents are almost certainly supervised by an attending physician who is ultimately responsible. Even if you didn't see this person, the residents were most likely responsible for at least discussing their findings with that attending or fellow who is the next one up the flowchart. They most likely bill for the attending physician service.

toofache32
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Re: Urgent! Heading to ER, surprise bills

Post by toofache32 » Tue Oct 24, 2017 8:11 am

Katietsu wrote:
Mon Oct 23, 2017 11:27 pm
toofache32 wrote:
Mon Oct 23, 2017 10:22 pm
Katietsu wrote:
Mon Oct 23, 2017 8:44 pm

From Healthcare.gov:

Out-of-network emergency care is covered under all insurance plans sold after March 23rd, 2010 as part of Ten Essential Benefits under the Affordable Care Act.

Insurance plans can't require higher copayments or coinsurance if you get emergency care out-of-network and they cannot require prior approval either. All non-emergency care must be done in-network to be covered and may require prior approval.

If your insurer is trying to bill you for the care you may have to appeal their decision.

Grandfathered plans bought before March 23, 2010 may not follow this same rule. Short term health insurance and some other coverage types may also not follow this rule.

If you get any care that is not strictly emergency care, out-of-network rates may apply. So always be very careful with this and make sure you are communicating with your insurance provider so you don't get blindsided by extra costs. Some plans will have a separate out-of-pocket maximum and deductible, so keep that in mind too.
This refers to insurance companies, not providers. In other words, out of network care that is "covered" does not mean paid in full. If they don't pay the entire bill then the remainder is on the patient. And it's an enormous fight to get the insurance company to pay. As a surgical subspecialist, I never ever got paid for OON emergency care which is one reason I stopped taking call in one of my hospitals. The ophthomologists stopped years ago for the same reason.
Thank you for the additional information. I did not realize balance billing following emergency care was still allowed in much of the country.
This entire "balance billing" concept is incredibly flawed because it assumes that the insurance payment is reasonable in the first place. Insurance companies often pay less than what it costs to provide the care. Let's be boglehead about this...if I show up to the ER to see a patient and cannot get paid, what would the boglehead recommendation be regarding continuing to accept requests to see patients in the ER? If insurance companies would pay reasonable rates, providers would WANT to sign up and this discussion would not exist.

toofache32
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Re: Urgent! Heading to ER, surprise bills

Post by toofache32 » Tue Oct 24, 2017 8:18 am

munemaker wrote:
Tue Oct 24, 2017 3:20 am
MulesFan wrote:
Tue Oct 24, 2017 12:03 am
A year ago I fell & broke both wrists. Off to the ER, surgery & home to recover. A few weeks later, the bills started rolling in. I have a HDLP plan & paid bills except the anesthesiologist statement, which indicated it was with the insurance company being reviewed (billing told me not to pay yet). After receiving 3 or 4 statements they stopped coming, so I figured insurance had paid. Then this spring letters from debt collector started rolling in. Spoke with insurance agent & she started investigating. She found out the bill was coded as out of network (hospital/ER are in network). I spoke with collection agency & explained situation & they put a hold on contacting me. It was quiet for a while but a few weeks ago I got a letter from insurance company stating they paid about 10% of the bill & I still owe about $2,400. I’m working with insurance agent again to see if bill can get recoded but at this point it appears the anesthesiologist is able to bill as out of network even though it was in our local hospital. It certainly never occurred to me to ask him if he was going to bill me in network or out of network!
There is a term for this despicable practice: balance billing
How do you know the in-network fees are reasonable? That is what everyone assumes here.
HIinvestor wrote:
Tue Oct 24, 2017 3:43 am
Balance billing IS very unfair to patients, especially since we are not in a position to know which folks who provide our care are in or out of network, especially in an emergency or urgent situation. The cost difference can be VERay significant!
I agree it's unfair to all parties involved. It's also unfair to those ER providers, but nobody ever talks about that for some reason. ER providers are not able to know if the patients (or their insurance) will be in-network or pay. You don't get to choose your doctors in the ER. Similarly the ER doctors don't get to choose their paying patients, especially in emergency situations.

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Re: Heading to ER, surprise bills [update: home again]

Post by LadyGeek » Tue Oct 24, 2017 3:56 pm

This thread has run its course and is locked (devolving into general rant). See: Personal Finance
Note that topics must be directly connected to your (or your friend's or family's) financial life. General comments or complaints about these topics will be locked or removed.
A number of posts ranting about health care workers vs. firefighter salaries were also removed.
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