Health Insurance Out of Network ruling issue

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jeam3131
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Re: Health Insurance Out of Network ruling issue

Post by jeam3131 »

california_folks wrote: Wed Jun 15, 2022 4:52 pm
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
That looks like something for travel coverage. The SPD is usually 50-200 pages and goes through a bunch of rules and exclusions. It's usually available on either your HR website or insurance company website. If not, you might have to contact your HR dept and ask for it. Can be hard to get a hold of sometimes, which makes no sense. It shouldn't be a secret.
twh
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Re: Health Insurance Out of Network ruling issue

Post by twh »

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.
This is why a plan with a carrier that has a nationwide network is a good idea.
This is also why a plan with a not-killer out-of-network maximum out-of-packet is a good idea.
And, all of the above is the best choice.
Northern Flicker
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Re: Health Insurance Out of Network ruling issue

Post by Northern Flicker »

jeam3131 wrote: If the doctor is not employed by the hospital, they are almost always part of some external group that signs the contracts.
You are making a semantic distinction. I wasn’t claiming each individual doctor personally signs a contract with an insurer. Of course they are part of a group organization that signs the contract. But that group collectively is the provider, and chooses or doesn’t choose to sign a contract with an insurer.
cubs1999
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Re: Health Insurance Out of Network ruling issue

Post by cubs1999 »

Northern Flicker wrote: Wed Jun 15, 2022 12:59 pm
investorpeter wrote:
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.

My message, somehow I broke the quote:
I've done some research on med evac. Most of these med evac insurance require that the evacuation be medically necessary. This means if person is stable and treatment is available at that hospital, then the person won't be moved. There are some policies or memberships (for example there's an outfit called "medjet" that offer medical evacuation as some sort of membership plan). Medjet claims on their website that they will provide medical evacuation to a local hospital without that medically necessary clause. In theory, if I get hospitalized 100+ miles (I think that's the minimum distance but haven't read the terms in a few years), I can get moved to a local hospital and finish of the hospitalization there. Regular travel benefits, again, would require me to stay wherever I was admitted as long as I'm stable there and can receive the care required there.

It has often been suggested to both get some sort of medical travel insurance (especially when traveling out of the country) and then a medjet type thing (I think there are other companies as well) that has separate evac policy/membership.

Fortunately, I've never had to test these benefits.
mega317
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Re: Health Insurance Out of Network ruling issue

Post by mega317 »

Northern Flicker wrote: Wed Jun 15, 2022 6:38 pm
jeam3131 wrote: If the doctor is not employed by the hospital, they are almost always part of some external group that signs the contracts.
You are making a semantic distinction. I wasn’t claiming each individual doctor personally signs a contract with an insurer. Of course they are part of a group organization that signs the contract. But that group collectively is the provider, and chooses or doesn’t choose to sign a contract with an insurer.
There is always cross talk in these threads between people who use provider to mean the human who the patient sees, and those who use provider to mean the entity that signs the contract with the insurer. And in almost no circumstance does any definition of "provider" definition have any leverage at all.
Hebell
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Re: Health Insurance Out of Network ruling issue

Post by Hebell »

What I have learned from this, is that when my husband retires in 15 months and we start traveling around the United States, I'm going to get travel insurance even inside the country. I plan to be on COBRA while my husband is on Medicare. Our Cobra plan is national, because my husband's job was in the aviation industry which required a national plan. But we do a lot of canoeing in remote areas and the OPs original post about evacuating certainly got my attention.
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ResearchMed
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Re: Health Insurance Out of Network ruling issue

Post by ResearchMed »

Hebell wrote: Wed Jun 15, 2022 11:28 pm What I have learned from this, is that when my husband retires in 15 months and we start traveling around the United States, I'm going to get travel insurance even inside the country. I plan to be on COBRA while my husband is on Medicare. Our Cobra plan is national, because my husband's job was in the aviation industry which required a national plan. But we do a lot of canoeing in remote areas and the OPs original post about evacuating certainly got my attention.
IF you are interested in that MedJetAssist, we always get the annual plan (well, pre-Covid, and again, when we start traveling again). That coverage is if you are at least 150 miles from home (last policy we had, ~ 2-3 years ago). You must be a hospital INPATIENT for it to kick in. At that point, if *you* want to be transferred to the hospital of your choice (e.g., your home hospital or some specialty hospital elsewhere in the USA, for USA-based coverage), AND if you are stable enough to be transported at least by an air ambulance with medical staff, then you call them and tell them to "take you to..." They only use fixed-wing aircraft, not helicopters. This isn't emergency/expedition type evacuation.
If you aren't stable enough for a full air ambulance, I'm guessing there are more dire things to worry about.

The nice thing about this coverage is that no bean counters need to decide if the transfer is "medically necessary", and also, no local medical staff are put in the possible awkward situation of declaring that they aren't quite up to caring properly for you, etc.

They do have "per trip" plans. However, that annual plan also covers short notice trips (more than 150 miles from home, of course) for work or to visit friends/family.

And of course, the coverage includes overseas, as long as a fixed-wing aircraft can be used.
Note that in some cases, if medically appropriate, they might send you back with flat bed business class and a medical attendant. Companion gets to sit in coach...
It depends what type of care you need during transport.

We came very close to calling them a few years ago. For the first time, I was in hospital overseas, and not doing well. At just about the time we were mumbling, "Should we call MJA...??" I started to get better. Magic words? Heh.

Anyway, our regular travel insurance paid for an extra week plus at our 5* hotel, for DH and then for me until I was fit to travel (physician documentation required, but they cover the bill for physician). And they paid for alternate transportation to the final leg of our trip as I was still unable to do 'everything' we had planned. (We guess they realized that was a lot less expensive than flying us home early and also paying for cancelling all the rest of the trip, but that's just our guess.)

We get our travel insurance (including MJA) through www.TripInsuranceStore.com and they helped us figure out some of the details of the end of that trip. No extra cost to the traveler. They were incredibly patient with us at first, with all of my questions, "but what if this?" - "and then what if that?"
There are many plans to choose from, from several differen travel insurers.

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Hebell
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Re: Health Insurance Out of Network ruling issue

Post by Hebell »

Researchmed - thank you, that is of considerable interest.
cubs1999
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Re: Health Insurance Out of Network ruling issue

Post by cubs1999 »

Hebell wrote: Thu Jun 16, 2022 12:36 am Researchmed - thank you, that is of considerable interest.
Yes, thank you for the better and more elaborate explanation of medjetassist. I signed up for a multi-year plan as there were significant savings in doing so and I was traveling a lot when I signed up(enough to make 100k airline status). Actually now I cut down on travel and probably will not me doing much for next year, but I do make a few trips outside that 150 mile range where the coverage would still apply.

I really got into this travel and medjet stuff about 15 years ago after my stepparent got really sick in China and they didn't have any coverage. Fortunately he survived and it didn't cost them as much as it could have but ever since then, I made sure we had coverage when I traveled with them internationally.
Northern Flicker
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Re: Health Insurance Out of Network ruling issue

Post by Northern Flicker »

mega317 wrote: Wed Jun 15, 2022 11:14 pm
Northern Flicker wrote: Wed Jun 15, 2022 6:38 pm
jeam3131 wrote: If the doctor is not employed by the hospital, they are almost always part of some external group that signs the contracts.
You are making a semantic distinction. I wasn’t claiming each individual doctor personally signs a contract with an insurer. Of course they are part of a group organization that signs the contract. But that group collectively is the provider, and chooses or doesn’t choose to sign a contract with an insurer.
There is always cross talk in these threads between people who use provider to mean the human who the patient sees, and those who use provider to mean the entity that signs the contract with the insurer. And in almost no circumstance does any definition of "provider" definition have any leverage at all.
Provider groups who staff hospital-based practices such as emergency room doctors have tremendous leverage over patients. A patient may choose an in-network hospital but has no choice over the ER doctor they will see once there. Often, the ER doctor is not even in any insurance networks, despite emergency care being defined as in-network under ACA.

The recent Federal balance billing law was passed to address the situation. It has not been uncommon for a patient to get bill that might have a line item for an out-of-network charge of around $2500+ for a 15-20 minute visit with the ER doctor, billed by that provider group and separate from the hospital facility charges and charges for services delivered by hospital employees.
mega317
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Re: Health Insurance Out of Network ruling issue

Post by mega317 »

Northern Flicker wrote: Thu Jun 16, 2022 11:37 am Provider groups who staff hospital-based practices such as emergency room doctors have tremendous leverage over patients.
I thought you meant leverage in negotiations with payors. But can you explain how this is leverage over patients? The fact that they aren't contracted with a payor is not leverage. On average they lose money on uninsured/underinsured.
SuzBanyan
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Re: Health Insurance Out of Network ruling issue

Post by SuzBanyan »

It may be that the surgery that happened days after your wife was stabilized in the ER would fall under the definition of “Urgent Care”, which OP said was covered when traveling out of the Plan area. In my Evidence of Benefit for a different provider, Urgent Services are defined as: “Those Covered Services rendered outside of the Plan Service Area (other than Emergency Services) which are Medically Necessary to prevent serious deterioration of your health resulting from unforeseen illness, injury or complications of an existing medical condition, for which treatment cannot reasonably be delayed until you return to the Plan Service Area.” Obviously, the applicable definition would be the one in the OP’s Evidence of Benefits.
Northern Flicker
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Re: Health Insurance Out of Network ruling issue

Post by Northern Flicker »

mega317 wrote: Thu Jun 16, 2022 1:14 pm
Northern Flicker wrote: Thu Jun 16, 2022 11:37 am Provider groups who staff hospital-based practices such as emergency room doctors have tremendous leverage over patients.
I thought you meant leverage in negotiations with payors. But can you explain how this is leverage over patients? The fact that they aren't contracted with a payor is not leverage. On average they lose money on uninsured/underinsured.
By not choosing to be in any insurance networks, they greatly increase the number of underinsured patients. But what you are implying is that the fees are set so that those patients who can pay are basically underwriting those who cannot. It takes leverage over those who can pay to make that happen,
mega317
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Re: Health Insurance Out of Network ruling issue

Post by mega317 »

Would be nice if WCI could weigh in because I think this is exactly his practice model. If I quote another random post of his does he get an alert? hehe
"Those who can pay" are generally insured people. I think what you're referring to is the people who aren't covered for their emergency care and will actually pay cash, maybe 10s of thousands, for the bill that shows up in the mail. That is a rare patient indeed. Doctors do not want to see these patients. Some can pay, most can't and won't. A PCP can have some control over their patient mix, such as limit the number of medicaid or uninsured patients, for example. ER sees who walks in.
Northern Flicker
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Re: Health Insurance Out of Network ruling issue

Post by Northern Flicker »

I’m referring not just to self-paying patients, but also to those who, despite being insured, got balance bills with line items from ER docs at the same or a similar level to what someone who is self-paying would get because the ER doc at the in-network hospital was not in the patient’s network.

Congress didn’t choose to pass a bill to address this in a vacuum. Members of Congress were hearing from their insured constituents who had received care from hospital emergency rooms.

A similar dynamic is with hospitalized patients seen by some specialists brought in by referral. When the patient has no input to the choice of physician, the physician does not have to participate in any insurance networks to have patients, or may just be out-of-network for the patient who sought care at an in-network hospital.

One solution (maybe not the ideal solution) would be just to have all doctors practicing in a hospital be employees of the hospital system. This is true (or at least generally true) at a Kaiser hospital. It does reduce choice for patients when they do choose their doctor for a hospital-based procedure.
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Re: Health Insurance Out of Network ruling issue

Post by Jack FFR1846 »

Northern Flicker wrote: Thu Jun 16, 2022 3:10 pm
One solution (maybe not the ideal solution) would be just to have all doctors practicing in a hospital be employees of the hospital system. This is true (or at least generally true) at a Kaiser hospital. It does reduce choice for patients when they do choose their doctor for a hospital-based procedure.
This would be wonderful. Would have made my situation easier.

I was at work and had chest pain. Went to the ER. They diagnosed and recommended cardiac cath. This particular hospital does not do stents or higher level work. I transferred to the top notch Boston hospital where I've had this kind of work done before. DW sent away the first ambulance because they were out of network. Took the next one. Ended up with 3 more stents.

So I get the bill from the first hospital (in network) that the ER doc is out of network...here's your bill. I appeal. Denied, he's out of network. I 2nd appeal with my comment "So next time I come into the hospital for chest pain, I need to stop the ER doc and ask if he's in network? If not, I need to wait until the next shift and then ask the next shift doc if he's in plan?". They paid the bill.

I could write a book on me as a patient trying to get accurate info from an insurance company. Like picking a new PCA and the network list has a doctor that's been dead for 3 years. Hmmm, good choice as I'm sure he's not too busy.
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ResearchMed
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Re: Health Insurance Out of Network ruling issue

Post by ResearchMed »

Jack FFR1846 wrote: Thu Jun 16, 2022 3:42 pm
Northern Flicker wrote: Thu Jun 16, 2022 3:10 pm
One solution (maybe not the ideal solution) would be just to have all doctors practicing in a hospital be employees of the hospital system. This is true (or at least generally true) at a Kaiser hospital. It does reduce choice for patients when they do choose their doctor for a hospital-based procedure.
This would be wonderful. Would have made my situation easier.

I was at work and had chest pain. Went to the ER. They diagnosed and recommended cardiac cath. This particular hospital does not do stents or higher level work. I transferred to the top notch Boston hospital where I've had this kind of work done before. DW sent away the first ambulance because they were out of network. Took the next one. Ended up with 3 more stents.

So I get the bill from the first hospital (in network) that the ER doc is out of network...here's your bill. I appeal. Denied, he's out of network. I 2nd appeal with my comment "So next time I come into the hospital for chest pain, I need to stop the ER doc and ask if he's in network? If not, I need to wait until the next shift and then ask the next shift doc if he's in plan?". They paid the bill.

I could write a book on me as a patient trying to get accurate info from an insurance company. Like picking a new PCA and the network list has a doctor that's been dead for 3 years. Hmmm, good choice as I'm sure he's not too busy.

How did your wife determine the network-or-not status of that first ambulance, and so quickly?
With chest pains, I'm not sure I'd want to send "the first ambulance" away...

We've had several occasions to call an ambulance over the past 15 years or so.
And we've never thought to ask about that. :shock:
I guess we assumed that the insurance would cover it as "emergency", but ... there's still that "out of network" glitch that the OON provider hasn't agreed to any particular fee structure and they could claim that the perhaps 3 miles of transport (plus coming to the house in the first instance) "costs" $75,000...

That's one huge problem I see with out of network insurance reimbursement structure, and especially that OON maximum.

Thus far, we have excellend Employer health insurance. I'm NOT looking forward to changing to Medicare with Retiree plan secondary.
(For a while, we think DH will try to carry a sign that shows, "Will Work For Benefits!" :wink: That's not entirely a joke.)

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Northern Flicker
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Re: Health Insurance Out of Network ruling issue

Post by Northern Flicker »

I’ve never seen a health insurance plan that lists in-network ambulances. I don’t think that exists where I live, but maybe it is a factor in transfers from rural areas.
DoubleComma
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Re: Health Insurance Out of Network ruling issue

Post by DoubleComma »

Northern Flicker wrote: Thu Jun 16, 2022 3:10 pm One solution (maybe not the ideal solution) would be just to have all doctors practicing in a hospital be employees of the hospital system. This is true (or at least generally true) at a Kaiser hospital. It does reduce choice for patients when they do choose their doctor for a hospital-based procedure.
Many laws against hospitals employing physicians directly to prevent monopolies. There are some exceptions, but it far more competitive for to patients when physician groups to contract to provide specific services to a Hopsital.

Even your Kaiser example is only partly true. Kaiser Permanente is essentially 3 companies; Kaiser Hospitals, Permanente Medical Group and the KP Insurance plan. The insurance plan contracts at a per member rate to the hospitals and medical group, this is where the money comes from. The medical group contracts with the hospitals to provide physician coverage. But the hospital definitely does NOT employee the physicians, although it appears that way.

One thing that make KP unique when compared to nearly every other health system is when a patient admits to a KP hospital they start losing money, opposed to most everywhere else that’s when the hospital starts making money. This is exactly why KP is so focused on prevention and invests so much in population health and new ways to deliver care and/or therapies.

The revenue sharing for Medicare and ACA plans with in Kaiser are little more complicated, but similar.

I’m not sure anyone would want hospitals employing physicians directly, it would give them far to much control in my opinion.
mega317
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Re: Health Insurance Out of Network ruling issue

Post by mega317 »

DoubleComma wrote: Thu Jun 16, 2022 7:03 pm One thing that make KP unique when compared to nearly every other health system is when a patient admits to a KP hospital they start losing money,
I’m surprised to read that. When a a Kaiser patient is admitted to my non Kaiser hospital, they typically want them back as soon as medically feasible. Is that just a PR move? Show they care about you kind of thing?
Northern Flicker
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Re: Health Insurance Out of Network ruling issue

Post by Northern Flicker »

I think Kaiser wants to deliver the care rather than pay for someone else to deliver it so that their population medicine model and internal treatment guidelines are used.

But not all Kaiser insurance is based on copays. Kaiser has insurance plans that work like other insurer’s plans, and community partners that, together with Kaiser providers, form a de facto provider network.

My point was that if you are treated in a Kaiser hospital it will be by Kaiser doctors and there will not be surprise bills from out of network providers, not whether the Kaiser doctors and hospitals are part of the same legal entities.
pharming2017
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Re: Health Insurance Out of Network ruling issue

Post by pharming2017 »

Battleborn33 wrote: Sun Jun 12, 2022 5:28 pm
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.
My wife and I had a baby in December 2021. We finally received invoices last month. Hopefully the delay will buy you time to get everything sorted out.
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Battleborn33
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Re: Health Insurance Out of Network ruling issue

Post by Battleborn33 »

We have a final resolution on this issue. Thank you to everyone for your comments and suggestions.

A brief recap. My wife fell hiking in March in Arizona; dislocated ankle, broken tibia and fibula. Arizona is not in network for our medical insurance but our policy included extended in-network coverage for urgent and emergency care and we used providers who were in this extended network. All services provided on the day of the accident were considered in-network but her surgery a few days later was coded out of network. It was the surgeon’s decision on the timing of the surgery.

We appealed the coverage ruling. We retained an attorney to assist and got a strongly worded letter from the surgeon explaining that my wife was not stabilized until surgery was completed.

The insurance company recently ruled in our favor on the appeal, this is a tremendous relief because the dollars are significant.

I have a few takeaways from this experience. First, I will be examining the details of the insurance I choose during the upcoming open enrollment period more throughly. We have been very fortunate in the sense that we’re both very healthy and consequently have little experience with the minutia of our insurance, this year will be the first time we’ve met our deductible in over 20 years. As we found though circumstances can change in a heartbeat. Second, while our experience with the provider side of health care was excellent, the administrative side was anything but, tremendous inefficiency to put it kindly. Third, I don’t fault the insurance company for the initial ruling, they were likely using a simple metric, once discharged from the ER the emergency is over and then you’re expected to travel back in-network for any additional care. Finally, the whole process is way too complicated, we’re fortunate, we had the resources and the ability to chase through all of this to get an outcome, many people are not so fortunate.
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ResearchMed
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Re: Health Insurance Out of Network ruling issue

Post by ResearchMed »

Very glad about the outcome.
Thanks for reporting back.

And... how is your wife!?

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Artful Dodger
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Re: Health Insurance Out of Network ruling issue

Post by Artful Dodger »

Battleborn33 wrote: Sun Oct 02, 2022 11:20 am We have a final resolution on this issue. Thank you to everyone for your comments and suggestions.

A brief recap. My wife fell hiking in March in Arizona; dislocated ankle, broken tibia and fibula. Arizona is not in network for our medical insurance but our policy included extended in-network coverage for urgent and emergency care and we used providers who were in this extended network. All services provided on the day of the accident were considered in-network but her surgery a few days later was coded out of network. It was the surgeon’s decision on the timing of the surgery.

We appealed the coverage ruling. We retained an attorney to assist and got a strongly worded letter from the surgeon explaining that my wife was not stabilized until surgery was completed.

The insurance company recently ruled in our favor on the appeal, this is a tremendous relief because the dollars are significant.

I have a few takeaways from this experience. First, I will be examining the details of the insurance I choose during the upcoming open enrollment period more throughly. We have been very fortunate in the sense that we’re both very healthy and consequently have little experience with the minutia of our insurance, this year will be the first time we’ve met our deductible in over 20 years. As we found though circumstances can change in a heartbeat. Second, while our experience with the provider side of health care was excellent, the administrative side was anything but, tremendous inefficiency to put it kindly. Third, I don’t fault the insurance company for the initial ruling, they were likely using a simple metric, once discharged from the ER the emergency is over and then you’re expected to travel back in-network for any additional care. Finally, the whole process is way too complicated, we’re fortunate, we had the resources and the ability to chase through all of this to get an outcome, many people are not so fortunate.
That's great!

Glad to hear it.
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Artful Dodger
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Re: Health Insurance Out of Network ruling issue

Post by Artful Dodger »

PS Hope your wife is doing well. :happy
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Battleborn33
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Re: Health Insurance Out of Network ruling issue

Post by Battleborn33 »

Left out an important point, my wife is recovering well. She estimates she’s 70% recovered, we’ve met a number of people who had the same injury and it apparently takes a full year to recover. My wife’s physical therapist tells her she’s ahead of schedule, my wife has been very disciplined following doctor’s and therapists instructions so I’m pretty sure she’ll completely recover. Thanks for asking about her.
jeam3131
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Re: Health Insurance Out of Network ruling issue

Post by jeam3131 »

Glad it worked out for you. Yes it can be infuriating and maddening. Unfortunaltey, many people give up and just pay, and the insurance company wins. They have this all calculated.
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Tubes
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Re: Health Insurance Out of Network ruling issue

Post by Tubes »

Thanks for the update. It is too bad it required the attorney fees. That's going to become more and more common.
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Battleborn33
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Re: Health Insurance Out of Network ruling issue

Post by Battleborn33 »

An update on our situation. As written previously the insurance company ruled in our favor on our appeal at the end of September. The wording in the letter advised that claims would be reprocessed, so we thought that's what would happen. What did happen is the insurance company reprocessed ONE claim, granted it was a big one, for the hospital charges on the day of the surgery. But that's it. In fact, it would appear to us that they need to reprocess every claim from the day of surgery forward because moving the day of surgery claims to in-network has us meeting our deductible and out of pocket maximum on that day, so claims past that day which we paid or which are not yet paid are affected. There are dozens of claims.

We've not paid many of the providers on the expectation that the insurance company is paying but now we're being threatened with collections so we contacted the insurance company and the individual we spoke to seemed very helpful so we'll see how the next little bit of time goes.

Reprocessing the claims seems like a relatively straightforward process doesn't it? Recode the claims on the day of the surgery to In-Network and then reprocess ALL the claims. Once again, we encounter the administrative side of health care and it's horrendous. Or is this further evidence of the insurance company stalling hoping that we'll go away?
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Re: Health Insurance Out of Network ruling issue

Post by hvaclorax »

Sorry if I’m late to this thread. I’ve done insurance reviews for BCBS for about 20 years. My advice might not be needed.
I would have asked for MD to MD review through the insurance company. We did them frequently and usually once the details were relayed to the MD reviewer, the review was quickly decided in the patient’s favor.
That being said, as many know, the administration side of the decision may not end up solving the problem. I think it’s because the billing system of both parties don’t communicate with each other. I’m not sure I, as reviewer, could help much beyond the MD reviewer involvement. I often asked the staff if I could be notified of the eventual outcome of these cases but not once did that happen. My decision went into a great void I’m afraid.
I’m sorry for your sad experience. I wonder why deny when the surgery needed to be done and likely the in network surgeon would charge the same. No savings there. Just a lot of dissatisfaction with multiple parties.
Insurance is of course a necessary evil in that some party or group must decide if charges are reasonable.
HVAC
OrangeKiwi
Posts: 295
Joined: Tue Oct 01, 2019 8:10 pm

Re: Health Insurance Out of Network ruling issue

Post by OrangeKiwi »

Battleborn33 wrote: Thu Dec 01, 2022 10:33 am Or is this further evidence of the insurance company stalling hoping that we'll go away?
It has been 9 months. The most charitable assumption I can make is that a boss in the insurance company is not properly staffing such that they can accomplish their work in a timely manner.

I was relayed a recent situation where a problematic department is known within a health insurance company, either due to bad staff or insufficient staffing, with the end result being that patients and providers waste tons of time and money due to the errors of the department.

However, there is no incentive for the bosses to fix this department, either by replacing bad employees or hiring more. The health insurance company even passed a CMS audit…which did not check a single thing this department did, even though the CMS is paying for the care. Which then helps the health insurance company executive justify understaffing and underinvesting in their employees, because it would only cost them more money for no gain (and who cares about all the extra time and money patients and providers spend?).

I assume if we go down the rabbit hole and ask the CMS executive why they did not properly audit the health insurance company, they will say they did not have sufficient budget to hire the quantity and quality of people needed to properly audit. And on and on it goes.
OpenMinded1
Posts: 1546
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Re: Health Insurance Out of Network ruling issue

Post by OpenMinded1 »

delete
OpenMinded1
Posts: 1546
Joined: Wed Feb 05, 2020 8:27 am

Re: Health Insurance Out of Network ruling issue

Post by OpenMinded1 »

clip651 wrote: Wed Jun 15, 2022 11:28 am
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
What you describe has happened to me many times. EOB indicates denied, but insurance ends up covering it eventually. My general rule is to do very little until I actually receive a bill. I generally don't even look at EOBs until I receive a bill.

After receiving a bill, I look at the EOB, paying particular attention to the codes. If I think I'm being billed for more than I should be, that's when I contact providers, billing offices, insurance companies, consumer advocates etc.

But I can certainly understand the OP's anxiety with such a large potential out-of-pocket amount being involved.
Topic Author
Battleborn33
Posts: 16
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Re: Health Insurance Out of Network ruling issue

Post by Battleborn33 »

23 months and we are finally at the conclusion.

Quick Recap:
My wife fell while hiking in the Arizona mountains, dislocating her ankle and breaking both bones in her lower left leg in March 2022.
Extracted via helicopter and ground ambulance to an ER.
Ankle relocated and bones stabilized, discharged that evening after consultation with surgeon.
Surgery performed a few days later after swelling went down.
Arizona not in our primary coverage area but we did have extended coverage area for urgent and emergency situations. Insurance company concluded the urgent situation ended at discharge from the ER, so they covered care to that point as in-network, but after discharge as out of network, for which we had a $70,000 deductible.
We didn't find this out until sometime post surgery about the coverage decision. We were advised we could appeal the coverage decision. We engaged an attorney and obtained a very well worded letter from the surgeon indicating the urgent situation continued until the surgery was complete and travel back to our coverage area prior to surgery could have been life threatening for my wife. The insurance company ruled in our favor on the appeal in September 2022 BUT only reprocessed ONE claim. They advised if we wanted any additional claims reprocessed we needed to get the providers to resubmit, we disagreed since they already had all the info they needed to reprocess. My wife complied a spreadsheet which contained all the claims in question and demonstrated the amount the insurance company still owed, we resent this spreadsheet at least four times because it continually got "misplace". We paid the providers because some much time had gone by that we didn't want any bill to be sent to collections.
Then we went through a multi-month period of stalling, false objections and just general non-responsiveness by the insurance company. SO, we decided to sue them in November of 2023. Amazingly once our attorney advised the person he been speaking to most recently of our intent to sue, he received a call from an attorney at the insurance company the same day!
A couple days later we were offered a settlement of less than what we were owed, which we declined. Subsequently they increased the settlement to the amount we said we were owed. We signed the settlement in December 2023 and their check arrived last week. Almost two years since the accident.

The decision to end the urgent coverage at the time of ER discharge doesn't seem unreasonable to me, it's a simple trigger event. We didn't have much experience utilizing our health insurance previously, had never reached the in-network deductible. We know so much more now. I relied on what I was told the night of the accident by the hospital regarding insurance coverage.
What I do have trouble with is the insurance company was not helpful, seemingly were deliberately stalling and didn't provide requested information or were simply nonresponsive most of the time and I'm pretty confident their customer service personnel were following a script to discourage us from pursing this any further.

We're fortunate that we had resources, friends in the legal and medical professions and the time to contest the decision. I've read that less than 10% of denied claims even get appealed.

Final note, my wife says she 95% recovered. She's resumed all the activities she enjoyed prior to the accident including hiking.

I'm detailing our experience hoping it may help someone else in the future. Know you rights, your insurance policy is a legal contract.
california_folks
Posts: 11
Joined: Tue Apr 27, 2021 6:39 pm

Re: Health Insurance Out of Network ruling issue

Post by california_folks »

Battleborn33 wrote: Thu Feb 08, 2024 4:01 pm 23 months and we are finally at the conclusion.
.........
I'm detailing our experience hoping it may help someone else in the future. Know you rights, your insurance policy is a legal contract.
Thank you, Battleborn33, so much for the update and the recap. I'm delighted to hear that everything has been sorted out and finalized for you and your wife. 🍻
May I please ask you a couple of follow-up questions to learn from your experience:

Did the settlement cover all your expenses, including attorney fees and retainer?

Could you kindly write a guide for people in similar situations based on your recent experience and knowledge? How would you recommend they proceed after the same incident with the ER/insurance, etc., under the same circumstances?

Your insights would be greatly appreciated.

Appreciate it!
Last edited by california_folks on Fri Feb 09, 2024 12:36 pm, edited 1 time in total.
RetireSoon90
Posts: 62
Joined: Mon Jan 01, 2018 7:13 am

Re: Health Insurance Out of Network ruling issue

Post by RetireSoon90 »

Thanks so much for the recap! We have multiple outdoor/overseas trips this year and your scenario is the one I wanted to be sure I was insured for. We have an NY ACA policy that does not cover out of state unless it is an emergency but from you recap you can see how they can decide which part is an emergency. I took out travel insurance through the trip insurancestore to hopefully mitigate any potential issues. I feel like the insurance company has too many subjective rules. Agreed you can fight the insurance company but I can't imagine the stress and number of hours you spent trying to made whole. Glad your wife is better!
Kendall
Moderator
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Re: Health Insurance Out of Network ruling issue

Post by Kendall »

I want to add two resources for anyone who is a consumer of private health insurance options. Marshall Allen is host of the podcast "An Arm and A Leg" and author of a book titled Never Pay the First Bill. He is a reporter with the Kaiser Family Foundation (lately called KFF, probably to be clear it has nothing to do with Kaiser Permanente).

Marshall Allen's reporting has made me a much more adept consumer of health services.

Battleborn33, thank you for sharing your experience. I'm so glad to hear your wife had a successful recovery and is back on the hiking trails.
valleyrock
Posts: 1061
Joined: Sun Aug 12, 2018 7:12 am

Re: Health Insurance Out of Network ruling issue

Post by valleyrock »

Yes, thanks for the recap.

It's too bad it came to this, but sometimes, eventually an attorney has to be brought in to deal with the insurance company's attorney, who really really wants to avoid going to court.

Can I ask: what sort of insurance policy or policies might have avoided all this? Could some sort of travel insurance helped? Like when you know you're going to be doing something that has some possibility of injury by climbing, etc., are there policies to purchase at a reasonable price?
Topic Author
Battleborn33
Posts: 16
Joined: Wed Jan 27, 2021 6:12 pm

Re: Health Insurance Out of Network ruling issue

Post by Battleborn33 »

I'm afraid I don't have any silver bullets with regard to insurance coverage. I had to purchase off the exchange in order to receive the tax credits (APTC). I wanted a plan with an HSA so we could continue to contribute. There were only two choices and one was clearly better, that's the one I chose in 2022 and again in 23 and 24 despite the issues with the provider.

I personally searched for supplemental coverage for our time out of network and I inquired with an insurance broker also both with no useable results.

Nowhere in our insurance contract document is there any language as specific as when an emergency event begins and ends. As mentioned, we didn't regard the insurance company's decision to use discharge from the ER as the event end as unreasonable.

This event was our first significant exposure to the healthcare industry in years beyond preventative care. Our experience with the providers was without exception outstanding and we felt grateful for the care that was provided and that it was top notch. Conversely, our experience with the administration side of healthcare was also very consistent....consistently poor. Hospitals, doctor's offices, insurance companies...all poor. I observed doctors shouldering some of the admin burden, because of their frustration with the process. I think this experience is one of the reasons we have the most expensive health care on the planet.
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