didn't phone insurance in emergency

[MissMolly]

This may apply to your situation

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

Doubtful. This law went into effect January 2022. His injury was in July 2021.

 

[RetMD21]

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

Talked to a nurse years ago who thought her son might have appendicitis. HMO rejected the ER bill since he was sent home after reassuring results on the e tests. The contact person told her that they would have covered for sure if
1.he was admitted or
2. he died.

One of the best things about traditional Medicare is the lack of network issues

 

[Bamaman]

Just pray there's no reason for you to ever be lifeflighted to a hospital.

 

[Sunset]

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

It's really hard to know.

One part says it's reduction due to contract with BCBS, the other part claims BCBS covered all but I have large deductibles for each portion.

BCBS also said while covering the facility portion to a large extent, that the doctor portion was coded as Urgent care (so was the facility) so they couldn't cover it.

All the paperwork shows the provider original costs and then some reduction in the net cost.

In some way I think BCBS covered a bunch or enforced the contracted rate just so I'd go away and they reasonably felt sorry for my being an idiot..

 

[Freedom56]

I would go through all your claims submitted to your insurance and review your EOBs and make sure that the proper codes were applied. With in-network providers you should be paying contracted rates if you have not met your deductible. Coding errors are very common and it's up to you to verify them. Also it's up to you to know which providers are in network but under the current law you cannot be billed for out-of-network rates due to a physician who is out of network by an in-network facility you visited for treatment.

On February 1st 2021, my wife had an MRI taken on her shoulder. We have Blue Shield bronze PPO. The provider billed the insurance company $1207 and we received a bill for $320.61 at the end of February 2021 which was the contracted rate applied to our deductible. I paid the bill on the same day I received it. Yesterday, over one year later, we received an email from our provider of a new billing statement in the amount of $480.02 for the same MRI with the same billing code for the same date (Feb 1, 2021). We checked the claims on our insurance site portal and verified the EOB and confirmed it was the same code as the original bill but different amounts. I called the medical billing customer service and spoke to the representative on behalf of my wife. I explained that we had already paid this bill per the contracted rate and did not understand why we were being billed $480.02 with the same procedure code. The representative explained that first bill was for the MRI and the second bill was for the radiologist reading the MRI but could not explain why the same CPT code was used and why it was billed over one year later. She stated that she was elevating it up to her supervisor for review. I stated that I have no plans to pay it without valid justification. After the call, I checked the regulations regarding medical billing time limits. In California, per SB 1175 (introduced 2017), a provider has up to 12 months from the date of service to file a claim and bill the insurance without exception. In some states the time limit is six months. When I went back online to check my wife's account and send them a message regarding SB 1175 limitations, I notice that the provider had already added a credit for the full amount of the bill as an "administrative discount". So you should also check the time limits in your state for medical billing.

 

[Sunset]

Just pray there's no reason for you to ever be lifeflighted to a hospital.

I heard on NPR last night about a guy in hospital, who wanted to be flown close to relatives a few States over and it had to be medically supervised the entire time.
His Bill was over $500,000 for that !
His insurance sent him a check for $70,000 which he forwarded to the air ambulance thinking that was the end of the story.
It wasn't.
Finally when it became public news the insurance and air ambulance stopped hounding him (no idea of the final price).

My issue was pretty minor compared to a $500,000 bill

 

[Sunset]

I would go through all your claims submitted to your insurance and review your EOBs and make sure that the proper codes were applied. With in-network providers you should be paying contracted rates if you have not met your deductible. Coding errors are very common and it's up to you to verify them. Also it's up to you to know which providers are in network but under the current law you cannot be billed for out-of-network rates due to a physician who is out of network by an in-network facility you visited for treatment.

On February 1st 2021, my wife had an MRI taken on her shoulder. We have Blue Shield bronze PPO. The provider billed the insurance company $1207 and we received a bill for $320.61 at the end of February 2021 which was the contracted rate applied to our deductible. I paid the bill on the same day I received it. Yesterday, over one year later, we received an email from our provider of a new billing statement in the amount of $480.02 for the same MRI with the same billing code for the same date (Feb 1, 2021). We checked the claims on our insurance site portal and verified the EOB and confirmed it was the same code as the original bill but different amounts. I called the medical billing customer service and spoke to the representative on behalf of my wife. I explained that we had already paid this bill per the contracted rate and did not understand why we were being billed $480.02 with the same procedure code. The representative explained that first bill was for the MRI and the second bill was for the radiologist reading the MRI but could not explain why the same CPT code was used and why it was billed over one year later. She stated that she was elevating it up to her supervisor for review. I stated that I have no plans to pay it without valid justification. After the call, I checked the regulations regarding medical billing time limits. In California, per SB 1175 (introduced 2017), a provider has up to 12 months from the date of service to file a claim and bill the insurance without exception. In some states the time limit is six months. When I went back online to check my wife's account and send them a message regarding SB 1175 limitations, I notice that the provider had already added a credit for the full amount of the bill as an "administrative discount". So you should also check the time limits in your state for medical billing.

Great information.

However, I was out of my network (lousy HMO), so that is my fault, and a strict reading of the rules would say I should pay the entire thing. At the same time, having in and out of network based on the doctor group instead of the insurance company plan type seems pretty slimy/tricky to me.

While they took their sweet time to send me a bill, it was less than 6 months from the incident by a couple of weeks.
If they send me any more bills from this incident, then I'll be searching very hard for the time limit in IL.

 

[Freedom56]

Great information.

However, I was out of my network (lousy HMO), so that is my fault, and a strict reading of the rules would say I should pay the entire thing. At the same time, having in and out of network based on the doctor group instead of the insurance company plan type seems pretty slimy/tricky to me.

While they took their sweet time to send me a bill, it was less than 6 months from the incident by a couple of weeks.
If they send me any more bills from this incident, then I'll be searching very hard for the time limit in IL.

If your provider failed to notify you of which providers near your home are in-network for urgent care, you may be entitled to in-network rates. When sign up for coverage, they normally inform you who your in-network urgent care providers are.

 

[badatmath]

If your provider failed to notify you of which providers near your home are in-network for urgent care, you may be entitled to in-network rates. When sign up for coverage, they normally inform you who your in-network urgent care providers are.

My insurance expects me to check. They do not notify me for sure. Nice if they did.

 

[Aerides]

If your provider failed to notify you of which providers near your home are in-network for urgent care, you may be entitled to in-network rates. When sign up for coverage, they normally inform you who your in-network urgent care providers are.

My insurance expects me to check. They do not notify me for sure. Nice if they did.

I'm not sure they are required to actively notify you, as in, send you a list of local providers, but they do make you aware of where to find out. And when you sign up for most insurance plans, you are asked to select providers you'd like in your plan. Mine has a thorough site with all the choices, I can search by type, by name, location, specialty, etc.

Anyway, the point of this thread isn't that (according to the title) the OP didn't call his insurance during the emergency, it's that he went to a facility that wasn't in his plan. OP hope you are well on the mend now!

So it's hopefully a good lesson for all of us to have some pre-selected emergency facilities selected which are in our networks, should such an unfortunate accident happen to any of us.