Do I have grounds to appeal or am I wasting my time?

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I apologize in advance for the wall of text.

Insurance carrier – Anthem Blue Cross State – CA

This all started several months ago when I woke up at 3am with sharp pains in my lower abdomen. Drove to ER, called me in around 4, they ran some tests, then admitted me around 9am for appendicitis and scheduled me for surgery later that day. The surgery got pushed back a couple times and eventually had the surgery around 8pm, went well, stayed the night at the hospital, and didn’t get discharged until the following day around 4pm. This timeline may be relevant as I was admitted for more than 24 hours.

Hadn’t hear anything in months and was growing worried about the potential hospital bill and didn’t want to get surprised by a collections agency so I called the hospitals billing department. My claim was still being settled, but they said I am going to be liable for my out of pocket maximum of 2k. I originally was going to dispute that my 100 copay paid at the ER be credited to the 2k so I called Anthem. The I explained the treatment I got and she essentially told me that because it was an emergency room service/admittance, the entire claim should be covered except for my 100 copay. However, I have an HMO and a different (unrelated) hospital through my medical group is actually settling the claim on Anthems behalf. I call their claims department and they are saying the hospital I went to billed the procedure as an outpatient procedure and that I was never actually admitted.

The claim rep through my medical group is saying “we are settling the claim based on what the hospital is billing for. If you were admitted and it was inpatient care, then it would be covered except for the copay. For outpatient, the coinsurqnce you are liable for reaches the 2k out of pocket max”

I have had several long conversations with the hmo medical group rep who says it’s out of her hands and will cover it the way it’s billed.

My conversations with the anthem rep have come down to her completely agreeing with me that this was an emergency service and should be covered but it’s ultimately the metrical groups call to settle the claim.

Now back to the billing department of the hospital I had the procedure at. I call them to dispute the way it was billed and asked if they could change the type of care with the billing codes to bill it as inpatient, as I was admitted through the ER. They told me I was never actually admitted, but only placed into observation. I’m not entirely sure what they consider observation… but I’m pretty sure treating a patient, putting them under GA, and performing a surgery goes well beyond the bounds of “observation.” I even referenced my paperwork… I have a letter from the Emergency Department discharging me to the hospital… then my discharge papers from my hospital stay clearly state “ADMITTING PHYSICIAN: xyz”

The claim rep had the audacity to tell me “you were admitted into observation, not to the hospital for inpatient care.” I voiced my opinions and ethical concerns about their arbitrary interpretation of the word “admitted” and to be quite honest, it feels borderline fraudulent. Regardless, she ultimately told me they bill based on my Physicians Orders and the records they have say “observation” and not “admit for inpatient”.

I called my surgeon’s office at his practice which is separate from the hospital. I asked them to pull up their records and the clerk on the phone pulled up some paperwork regarding my stay that used some language surrounding “inpatient” care specifically. I haven’t seen these records myself yet. I asked her to send them to me and the billing department of the hospital. I’m hoping this reference of inpatient care is enough to resolve it, however, I have my doubts because I don’t think it’s the official order through the hospital during my stay that said I was in “observation”.

What are my options here? Do I have even have grounds to dispute this? Or is this an unfortunate loophole that providers exploit to avoid coverage and I’m stuck paying the bill?

Is it a possibility to have the surgeon retroactively amend his orders that would classify me as “admitted” for inpatient care? Would that even be something they would do? Is that legal?

If I were to dispute this claim and file a grievance through Anthem, does this sound like I might have a legitimate case?

The way I see it… I went to the ER… they felt I needed to have surgery that day… I spent 30 hours hooked up to an IV in a hospital bed in my own room, had a surgery, and then was discharged by my admitting physician. Seem pretty cut and dry “emergency service”. Not that I had many positive feelings about our healthcare system to begin with, but getting swindled like this feels pretty disheartening.

Thank you for your time in reading this and your responses!

submitted by /u/PanchoSeranto
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I apologize in advance for the wall of text. Insurance carrier – Anthem Blue Cross State – CA This all started several months ago when I woke up at 3am with sharp pains in my lower abdomen. Drove to ER, called me in around 4, they ran some tests, then admitted me around 9am for appendicitis and scheduled me for surgery later that day. The surgery got pushed back a couple times and eventually had the surgery around 8pm, went well, stayed the night at the hospital, and didn’t get discharged until the following day around 4pm. This timeline may be relevant as I was admitted for more than 24 hours. Hadn’t hear anything in months and was growing worried about the potential hospital bill and didn’t want to get surprised by a collections agency so I called the hospitals billing department. My claim was still being settled, but they said I am going to be liable for my out of pocket maximum of 2k. I originally was going to dispute that my 100 copay paid at the ER be credited to the 2k so I called Anthem. The I explained the treatment I got and she essentially told me that because it was an emergency room service/admittance, the entire claim should be covered except for my 100 copay. However, I have an HMO and a different (unrelated) hospital through my medical group is actually settling the claim on Anthems behalf. I call their claims department and they are saying the hospital I went to billed the procedure as an outpatient procedure and that I was never actually admitted. The claim rep through my medical group is saying “we are settling the claim based on what the hospital is billing for. If you were admitted and it was inpatient care, then it would be covered except for the copay. For outpatient, the coinsurqnce you are liable for reaches the 2k out of pocket max” I have had several long conversations with the hmo medical group rep who says it’s out of her hands and will cover it the way it’s billed. My conversations with the anthem rep have come down to her completely agreeing with me that this was an emergency service and should be covered but it’s ultimately the metrical groups call to settle the claim. Now back to the billing department of the hospital I had the procedure at. I call them to dispute the way it was billed and asked if they could change the type of care with the billing codes to bill it as inpatient, as I was admitted through the ER. They told me I was never actually admitted, but only placed into observation. I’m not entirely sure what they consider observation… but I’m pretty sure treating a patient, putting them under GA, and performing a surgery goes well beyond the bounds of “observation.” I even referenced my paperwork… I have a letter from the Emergency Department discharging me to the hospital… then my discharge papers from my hospital stay clearly state “ADMITTING PHYSICIAN: xyz” The claim rep had the audacity to tell me “you were admitted into observation, not to the hospital for inpatient care.” I voiced my opinions and ethical concerns about their arbitrary interpretation of the word “admitted” and to be quite honest, it feels borderline fraudulent. Regardless, she ultimately told me they bill based on my Physicians Orders and the records they have say “observation” and not “admit for inpatient”. I called my surgeon’s office at his practice which is separate from the hospital. I asked them to pull up their records and the clerk on the phone pulled up some paperwork regarding my stay that used some language surrounding “inpatient” care specifically. I haven’t seen these records myself yet. I asked her to send them to me and the billing department of the hospital. I’m hoping this reference of inpatient care is enough to resolve it, however, I have my doubts because I don’t think it’s the official order through the hospital during my stay that said I was in “observation”. What are my options here? Do I have even have grounds to dispute this? Or is this an unfortunate loophole that providers exploit to avoid coverage and I’m stuck paying the bill? Is it a possibility to have the surgeon retroactively amend his orders that would classify me as “admitted” for inpatient care? Would that even be something they would do? Is that legal? If I were to dispute this claim and file a grievance through Anthem, does this sound like I might have a legitimate case? The way I see it… I went to the ER… they felt I needed to have surgery that day… I spent 30 hours hooked up to an IV in a hospital bed in my own room, had a surgery, and then was discharged by my admitting physician. Seem pretty cut and dry “emergency service”. Not that I had many positive feelings about our healthcare system to begin with, but getting swindled like this feels pretty disheartening. Thank you for your time in reading this and your responses!
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