Hi r/HealthInsurance, I am in WA State and have an Individual Health Plan through WA State marketplace Insurance through Molina Commercial.
I was visiting some folks in a farther away county where I live but still in WA, went skateboarding with my brother while he was in town, and unfortunately took a fall that broke my foot in several places. We went to the Urgent Care, and referred me to an Orthopedics in town to get it further checked out. Because my Urgent Care did take my insurance and was in-network, asked if that Ortho would be as well, they said yes. When I went to my Ortho appointment, I also asked again when they take your insurance to confirm they took mine and in-network, they said yes.
My diagnosis from the Ortho Doctor from an X-Ray and CT Scan indicated I should get surgery done on my foot ASAP, as this diagnosis was already 8 days from the incident date, if delayed could have permanent damage to my foot/not walk on it again. So they scheduled a surgery for the next day, was considered ’emergent’ and learned from hospital billing was coded as such. Anyways come surgery day before I went up to change, they did have me talk with a billing person, asked my insurance again, I asked again if this is in-network and they take it, they said yes.
After the surgery, find out in my EOB’s I have some statements in-network, some not. Of course the most expensive ones, for the doctor group and the hospital, said they are out-of-network, and I’m being billed from the hospital now as all my responsibility. I called the hospital billing, first they said some authorizations might not have been done, told me not to worry. A month passes, get another bill the same and wondering wtf is going on here. I call my Insurance and they tell me it is being denied due to not having an authorization. Called the hospital again, and I forget if they said they aren’t authorizing due to being out-of-network, or the authorization was never sent, which they said they’d follow up on. THEN I call my insurance again and then they tell me this hospital is out-of-network.
I made an initial complaint about that, was denied once so appealing that, stating at all points the hospital expressly told me my Insurance was in-network, otherwise they shouldn’t have admitted me to the hospital? They should have told me if it wasn’t in-network I would sign something stating I’m liable for some or all the expenses, but never happened. And here I am liable for all of it anyways.
I’m not sure how this occurs due to the emergent nature of case, I didn’t have the luxury of “shopping around” and also I didn’t call my insurance beforehand about any in or out of network because at all points from the hospital they said they were in-network and took Molina. And Molina may look at this and not being exactly a life-or-death emergency, won’t want to cover this even if it was an emergency hospital code wise.
I can’t afford to pay this, the hospital does have a financial assistance program which I applied but unsure if I’ll qualify, but this is BS I thought I was careful with some due diligence, and there probably weren’t any hospitals within a 75mile radius, like as if I had an option. And for them to lie to my face about checking and saying my Insurance was in-network extremely infuriating.
Just wondering if I have to argue with the hospital what really happened, pretty sure the ball was dropped on their end, and I could afford an in-network rate or my Insurance’ maximum out of pocket $8000 (For my plan, there’s only a max for in-network, of course) but $24000 all to me for foot surgery? I hate this country.
submitted by /u/EPS21
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Hi r/HealthInsurance, I am in WA State and have an Individual Health Plan through WA State marketplace Insurance through Molina Commercial. I was visiting some folks in a farther away county where I live but still in WA, went skateboarding with my brother while he was in town, and unfortunately took a fall that broke my foot in several places. We went to the Urgent Care, and referred me to an Orthopedics in town to get it further checked out. Because my Urgent Care did take my insurance and was in-network, asked if that Ortho would be as well, they said yes. When I went to my Ortho appointment, I also asked again when they take your insurance to confirm they took mine and in-network, they said yes. My diagnosis from the Ortho Doctor from an X-Ray and CT Scan indicated I should get surgery done on my foot ASAP, as this diagnosis was already 8 days from the incident date, if delayed could have permanent damage to my foot/not walk on it again. So they scheduled a surgery for the next day, was considered ’emergent’ and learned from hospital billing was coded as such. Anyways come surgery day before I went up to change, they did have me talk with a billing person, asked my insurance again, I asked again if this is in-network and they take it, they said yes. After the surgery, find out in my EOB’s I have some statements in-network, some not. Of course the most expensive ones, for the doctor group and the hospital, said they are out-of-network, and I’m being billed from the hospital now as all my responsibility. I called the hospital billing, first they said some authorizations might not have been done, told me not to worry. A month passes, get another bill the same and wondering wtf is going on here. I call my Insurance and they tell me it is being denied due to not having an authorization. Called the hospital again, and I forget if they said they aren’t authorizing due to being out-of-network, or the authorization was never sent, which they said they’d follow up on. THEN I call my insurance again and then they tell me this hospital is out-of-network. I made an initial complaint about that, was denied once so appealing that, stating at all points the hospital expressly told me my Insurance was in-network, otherwise they shouldn’t have admitted me to the hospital? They should have told me if it wasn’t in-network I would sign something stating I’m liable for some or all the expenses, but never happened. And here I am liable for all of it anyways. I’m not sure how this occurs due to the emergent nature of case, I didn’t have the luxury of “shopping around” and also I didn’t call my insurance beforehand about any in or out of network because at all points from the hospital they said they were in-network and took Molina. And Molina may look at this and not being exactly a life-or-death emergency, won’t want to cover this even if it was an emergency hospital code wise. I can’t afford to pay this, the hospital does have a financial assistance program which I applied but unsure if I’ll qualify, but this is BS I thought I was careful with some due diligence, and there probably weren’t any hospitals within a 75mile radius, like as if I had an option. And for them to lie to my face about checking and saying my Insurance was in-network extremely infuriating. Just wondering if I have to argue with the hospital what really happened, pretty sure the ball was dropped on their end, and I could afford an in-network rate or my Insurance’ maximum out of pocket $8000 (For my plan, there’s only a max for in-network, of course) but $24000 all to me for foot surgery? I hate this country.
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