didn't phone insurance in emergency

[Sunset]

Last July I fell down the basement stairs near 6pm.
My DW heard and came to see me crumpled on the floor.
I wasn't dying right then, so I said due to pain I should get xrays but not take the amublance as I could hobble to the car. I was concern about the cost of ambulance and hospital emergency.

We went to an Urgent care we know.
I got x-rays, antibiotics, narco, and bandages.
Good news nothing was broken, I was sore for weeks.

I just got the medical bill for for it (it was so slow I though it was fully covered):

Billed to BCBS $1,846.00
Insurance Covered -$470.72
Remaining Responsibility $1,375.28

Physician Services Billed $242.00
Insurance Covered $0.00
Your Balance $242.00

Total: $1,617.28

I called my insurance group, they said I didn't get a referral or prior approval...(would they have denied me?). I asked for an EOB, they said because it's HMO they don't send them to patients.

Had I gone for sprained ankle or stubbed toe, I would totally understand it's my fault for not going to see my doctor, but this was in my mind an emergency and my choice was hospital or urgent care as xrays were needed.
Two weeks later I saw my Doctor to ensure the bruising still showing wasn't internal bleeding.

We have BCBS HMO, both on same plan. The Urgent care is in DW's group network, but not in my group network, as we have different doctors (I think that's how it works).
But BCBS does consider the Urgent care in network as they affected (paid?) $420 towards center, none towards doctor cost.

Anything I can do to reduce the final costs to me ?

 

[Aerides]

So it sounds (despite all the details) like you went to an out-of-network provider. They paid some of it, but not as much as they would have paid were it In-Network.

I think that, A) going to emergency) or B) going to urgent care, both were reasonable decisions, but the issue doesn't sound like that's the problem - or that you didn't contact your insurance before deciding - it's the choice of actual providers, and whatever codes and services they billed for.

I'm assuming your patient portion is in line with your out-of-network deductible per your plan? If so I doubt there's anything you can do to reduce your amount due.

(if I've misunderstood pls clarify).

the lesson here is to have an idea of all the emergency coverages in your plan, so you can make the right decision in times of dire need. We found out this summer that our best ER hospital is in network only for ER, not for in-patient. I didn't find that out until the hospital admin called me while DH was in the ER, letting me know they were admitting him and once they did, he was out-of-network...

Didn't care at that point, and the hospital was the best, and closest, and would knowing would not have changed our decision at the time (this was a "I'm calling 911!" emergency - all is good now).

 

[Jerry1]

There should be an appeal process. Use it to file an appeal for reconsideration. As you said, would they have denied it had they had prior notice? Would they have rather paid for an emergency room visit? Also, not sue about where you live but we’ve been encouraged to stay away from ER’s and hospitals right now due to the surge in COVID. I’d for sure throw that into the appeal if it applies in your area.

 

[Car-Guy]

All plans are different but for me, in such a case, I would have simply just gone to the hospital emergency room. There's a $50 flat fee regardless if I am admitted or not (with my plan) and no pre-authorizations required for expensive things like CT scans. There's different rules with urgent care/walk-in clinics, at least with my plan.

 

[Sunset]

Our plan says for Urgent care in network I pay $50 copay, Out of network is not covered. Has limitation: Must be affiliated with members chosen medical group or referral required.

So they paid $420, which suggests to me it's in network (as is in network for DW) but not in my medical group so that situation doesn't fit the choices.

My deductible is $1,250 so the charges are higher, and it's not my insurance sending the bill to me, but the Urgent Care center.

 

[travelover]

..........I called my insurance group, they said I didn't get a referral or prior approval............

Apparently you should've called them just before you fell down the stairs.

 

[badatmath]

I think it is common for an insurance company not to consider a broken bone an emergency. I have heard similar stories.

 

[Sarah S]

A definite long shot but have you confirmed it is too late for a back dated referral. The hmo that I had before medicare ( which was not BCBS) allowed them to be done for an entire year. I think they were outliers but it never hurts to ask.

 

[Sunset]

Apparently you should've called them just before you fell down the stairs.

I asked the phone person who answered for my group, if I had a heart attack should I phone them before going to the hospital near me that is out of network?
She said I didn't have to, they would "Probably" cover it

 

[Sunset]

A definite long shot but have you confirmed it is too late for a back dated referral. The hmo that I had before medicare ( which was not BCBS) allowed them to be done for an entire year. I think they were outliers but it never hurts to ask.

No I didn't even think of it, how strange that they would do it.

I'll put this on my list of things to ask, just in case.

 

[travelover]

I asked the phone person who answered for my group, if I had a heart attack should I phone them before going to the hospital near me that is out of network?
She said I didn't have to, they would "Probably" cover it

I'm sympathetic. DW broke a bone in her foot a few weeks ago and she went to her GP to have it X-Rayed. The EOB came with an explanation that "this service is not covered". WTF?

 

[RetiredAndLovingIt]

File an appeal with the insurance company and if that does not work, call the Urgent Care
and explain the situation and ask what they can do to reduce the price since you are on a fixed income. You should be able to get a significant discount off what is probably the retail price.
In other words try the "I'm old, senile and broke defense" and hopefully you will get some help there. I would also have them put it in writing if they agree to reduce the price so some collection agency does not start calling you in a couple of years.

 

[FLSUnFIRE]

My guess is you'll have better luck getting a reduction with the provider if prepared to pay cash and negotiate while giving a sob story about being out of network and poor. My policy clearly states only major bone breaks (femur, etc) are "emergencies" they will cover out of network.



This is a good reminder for all of us to be aware of our policies before we need them. I did make a mental note of the hospitals and doc-in-a-boxes that are covered under my policy.



When I sliced my foot open a few months ago I pulled up the policy app on my phone to call the provider to check wait times and confirm they were in network. They billed $270 for a tetanus booster and looking at my boo-boo that, fortunately, did not need sutures, I was responsible for $70. (About a quarter of the base bill... offer a quarter on the dollar when you call!)

 

[FLSUnFIRE]

All plans are different but for me, in such a case, I would have simply just gone to the hospital emergency room. There's a $50 flat fee regardless if I am admitted or not (with my plan) and no pre-authorizations required for expensive things like CT scans. There's different rules with urgent care/walk-in clinics, at least with my plan.

They actually incentivize the ER? Wow, I think I'd have to be dead before I'd agree to the ER! I've never been myself but did take my former wife before and the billed amounts are beyond ridiculous!

 

[Sunset]

My guess is you'll have better luck getting a reduction with the provider if prepared to pay cash and negotiate while giving a sob story about being out of network and poor. My policy clearly states only major bone breaks (femur, etc) are "emergencies" they will cover out of network.

This is a good reminder for all of us to be aware of our policies before we need them. I did make a mental note of the hospitals and doc-in-a-boxes that are covered under my policy.


When I sliced my foot open a few months ago I pulled up the policy app on my phone to call the provider to check wait times and confirm they were in network. They billed $270 for a tetanus booster and looking at my boo-boo that, fortunately, did not need sutures, I was responsible for $70. (About a quarter of the base bill... offer a quarter on the dollar when you call!)

I did add the in Network Urgent Care and the In Network Hospital (pretty far) to my phone so I have the number and addresses.
I'm ready for my heart attack now ...

I'll be Soooooo glad when I'm on Medicare.

 

[Car-Guy]

They actually incentivize the ER? Wow, I think I'd have to be dead before I'd agree to the ER! I've never been myself but did take my former wife before and the billed amounts are beyond ridiculous!

I don't think it was to incentivize using the ER, but just a recognition that "stuff" happens out of your control and not to penalize you for that... I expect if I went to the ER (only been once myself) and needed something like a non emergency CT scan, they'd refer me back to my PCP for scheduling and insurance authorization.

 

[Aerides]

I'll be Soooooo glad when I'm on Medicare.

Don't be so sure. Medicare still has networks and plans and differences...and things to know, providers that take your plan and don't... it's not all plain sailing.

 

[Sunset]

Don't be so sure. Medicare still has networks and plans and differences...and things to know, providers that take your plan and don't... it's not all plain sailing.

I'm going to sign up for a plan G , and will be sure to ask providers if they take Medicare.
I'm staying away from Advantage programs as it's too much like my HMO, and I'm getting clumsy

 

[Car-Guy]

Don't be so sure. Medicare still has networks and plans and differences...and things to know, providers that take your plan and don't... it's not all plain sailing.

Absolutely... My medicare advantage plan covers me on any doctor or facility that accepts medicare assignments. In other words, no networks. I suspect there are some service providers that don't accept medicare but I haven't found one yet. Also I wanted a plan that had a OOP max which I got... I've never hit the OOP max yet but I know it's coming. YMMV

 

[sweetana3]

You have to be proactive. My husband went for a colonoscopy and we got a bill denying the operating room. They paid everything else. Where did they want to do it, in the parking lot? It was a coding error.

We have also had to fight over a blood test. Doctor did not code it as a diagnostic test but some kind of general code. It has been months and we do not have any final paperwork. Difference is $300. Told the doctor's office that we were not very pleased with the communication and to not order any general tests. They took it, Vit. D test, off the next panel request.

 

[38Chevy454]

I would call the Urgent Care and the doctor to ask them if they are considered in-network or not. Also ask if they can check the coding to see if there was an error. Or resubmit with agreement to accept what your ins will pay, plus a reduced OOP deductible payment from you. I wold guess that you can probably get some reduction in the amount you pay, whether from the ins company paying more, or you negotiating a reduced amount.

 

[Sunset]

Just so folks know how the story is ending:

After a bunch of communicating the bill is down a further $578, now it's just under 1/2 of the original total.

I've decided to pay the remaining bill, rather than continue to fight it, since I feel I did make a mistake by not being prepared for an emergency so certainly I have some blame.

Besides, the expense now of ~$1K , I can't rationally argue spending more time on it while I drool over taking some cruise costing well over $4K or more..

 

[youbet]

Was the reduction in the amount you owe due to the insurance company paying more, the provider billing less or some combination?

 

[ivinsfan]

Sunset did you ever have them make note of the time of day this happened? Wonder if that would make a difference?

 

[foxcreek9]

This may apply to your situation

https://www.cms.gov/newsroom/fact-s...nd-your-rights-against-surprise-medical-bills