Greetings all.
I hope my situation is addressing the issue in the correct subreddit. If not, please feel free to advise or let me know where to elicit help.
TL:DR – Long story short, I was hit by a car going 45+ mph as a pedestrian while crossing the street, spent 2 weeks in an “out-of-network” hospital, and charged a $122,000 balanced bill by the provider (hospital) after my insurance’s 50% “out of network” coverage was issued. The total hospital insurance claim was around $220,000. The insurance claim was NOT coded as an emergency room admission so insurance did not cover costs as such. What recourse do I have to dispute this bill? Any advice or help is greatly appreciated! ____________________________________________________________________________________________________________
As mentioned above, I was in an auto vs. pedestrian accident. I was knocked unconscious with no heartbeat, a severe concussion, and sustained multiple injuries while EMS rushed me to the emergency room of the nearest trauma center. I literally woke up in the hospital with a compound leg break, multiple spine fractures, a fractured rib, and many lacerations, abrasions, and bruises.
I spent two weeks in an unstable condition at the hospital. I was transferred from the ER, to ICU, stepped down to general unit, then re-admitted to the ICU because my vitals were all over the place. I had emergency leg surgery, but only after requiring clearance by the neuro department due to my neck/spine fractures, to be safe to undergo the procedure about 5 days after my ER admission. I had no choice or option to choose my health provider while being rushed to the hospital (while unconscious, obviously) by EMS, and I was not allowed to be transferred to another “in-network” institution or discussed what the medical costs of service would be while hospitalized.
With that said, I am happy to be alive thanks to the work of the health-care providers and thankful for having health insurance, despite this potential clusterfuck of a financial situation.
The issue is how the insurance claim was diagnostically coded as a “hospital stay” by the provider. My insurance did process the claim as it was received, but the hospital, a large trauma center in a large city mostly dealing with under-insured or un-insured patients, has frozen all bill processing due to COVID-19.
After receiving the EoB from my insurance in the mail, I called an insurance representative who explained to me why the insurance paid only the 50% out-of-network rate. She said the claim was not coded as an emergency room admission, despite the fact I absolutely was admitted to the ER.. She said I should call the hospital to request the hospital to update and resubmit their claim to the insurance company for further review. Per my health insurance policy, “for covered services incurred at an Out-of-Network hospital as the result of an emergency hospital admission (admitted through the emergency room), the Plan will pay 90% of the Allowable Amount.” The insurance company can also pay “out-of-network” providers at an “in-network” coverage rate if the service was an emergency room admission.
As such, I spent all day making attempts to call the hospital billing department only to speak with call-center agents who could not address this issue or couldn’t transfer me to a person/department who could speak on this problem. The situation is complicated as well, because COVID-19 has all hospital administrative staff and state county employees (as this hospital is a county hospital) either working from home or furloughed. The process of even speaking to someone about this is truly a challenge. I know I can request an itemized bill, and I will make requests for my insurance company to contact the hospital regarding this issue, although I can’t imagine that is within their responsibility or concern.
I’m worried because these issues are time sensitive and the time to facilitate anything involved in this process has slowed down considerably these days. I need to communicate with hospital staff regarding this inconsistency before this bill potentially gets sent to a collections agency wherein it cannot be changed, I believe? I also need to determine if this issue requires an appeal to my insurance company.
It seems as if this is a simple error that can be corrected, but also seems entirely difficult to resolve this situation. The hospital billing department call center people suggested that I wait for the hospital bill and apply for a financial assistance program. There is no way in hell I can afford this bill or wait to resolve this issue before it is too late. I know that hospitals have financial assistance programs, but what other options do I have besides maybe hiring a lawyer or starting a GoFundMe as a desperate last resort?
I hope this post is clear and sensible, and I sincerely hope no one else has to deal with this type of situation.
Thank you all for your help and any support/advice/suggestions offered!
submitted by /u/happi_n_hurting
[link] [comments]
Greetings all. I hope my situation is addressing the issue in the correct subreddit. If not, please feel free to advise or let me know where to elicit help. TL:DR – Long story short, I was hit by a car going 45+ mph as a pedestrian while crossing the street, spent 2 weeks in an “out-of-network” hospital, and charged a $122,000 balanced bill by the provider (hospital) after my insurance’s 50% “out of network” coverage was issued. The total hospital insurance claim was around $220,000. The insurance claim was NOT coded as an emergency room admission so insurance did not cover costs as such. What recourse do I have to dispute this bill? Any advice or help is greatly appreciated! ____________________________________________________________________________________________________________ As mentioned above, I was in an auto vs. pedestrian accident. I was knocked unconscious with no heartbeat, a severe concussion, and sustained multiple injuries while EMS rushed me to the emergency room of the nearest trauma center. I literally woke up in the hospital with a compound leg break, multiple spine fractures, a fractured rib, and many lacerations, abrasions, and bruises. I spent two weeks in an unstable condition at the hospital. I was transferred from the ER, to ICU, stepped down to general unit, then re-admitted to the ICU because my vitals were all over the place. I had emergency leg surgery, but only after requiring clearance by the neuro department due to my neck/spine fractures, to be safe to undergo the procedure about 5 days after my ER admission. I had no choice or option to choose my health provider while being rushed to the hospital (while unconscious, obviously) by EMS, and I was not allowed to be transferred to another “in-network” institution or discussed what the medical costs of service would be while hospitalized. With that said, I am happy to be alive thanks to the work of the health-care providers and thankful for having health insurance, despite this potential clusterfuck of a financial situation. The issue is how the insurance claim was diagnostically coded as a “hospital stay” by the provider. My insurance did process the claim as it was received, but the hospital, a large trauma center in a large city mostly dealing with under-insured or un-insured patients, has frozen all bill processing due to COVID-19. After receiving the EoB from my insurance in the mail, I called an insurance representative who explained to me why the insurance paid only the 50% out-of-network rate. She said the claim was not coded as an emergency room admission, despite the fact I absolutely was admitted to the ER.. She said I should call the hospital to request the hospital to update and resubmit their claim to the insurance company for further review. Per my health insurance policy, “for covered services incurred at an Out-of-Network hospital as the result of an emergency hospital admission (admitted through the emergency room), the Plan will pay 90% of the Allowable Amount.” The insurance company can also pay “out-of-network” providers at an “in-network” coverage rate if the service was an emergency room admission. As such, I spent all day making attempts to call the hospital billing department only to speak with call-center agents who could not address this issue or couldn’t transfer me to a person/department who could speak on this problem. The situation is complicated as well, because COVID-19 has all hospital administrative staff and state county employees (as this hospital is a county hospital) either working from home or furloughed. The process of even speaking to someone about this is truly a challenge. I know I can request an itemized bill, and I will make requests for my insurance company to contact the hospital regarding this issue, although I can’t imagine that is within their responsibility or concern. I’m worried because these issues are time sensitive and the time to facilitate anything involved in this process has slowed down considerably these days. I need to communicate with hospital staff regarding this inconsistency before this bill potentially gets sent to a collections agency wherein it cannot be changed, I believe? I also need to determine if this issue requires an appeal to my insurance company. It seems as if this is a simple error that can be corrected, but also seems entirely difficult to resolve this situation. The hospital billing department call center people suggested that I wait for the hospital bill and apply for a financial assistance program. There is no way in hell I can afford this bill or wait to resolve this issue before it is too late. I know that hospitals have financial assistance programs, but what other options do I have besides maybe hiring a lawyer or starting a GoFundMe as a desperate last resort? I hope this post is clear and sensible, and I sincerely hope no one else has to deal with this type of situation. Thank you all for your help and any support/advice/suggestions offered!
submitted by /u/happi_n_hurting [link] [comments]Read Morer/HealthInsurance