Insurance Reimbursement and Hospital Bills...

[Fergasun]

I got the insurance statement from my wife's birth of our second child (I know there will be congratulations, thanks!). On the statement it said that our hospital was out-of-network (I'm fortunate to have BCBS PPO), but I already know the hospital was one of their "preferred" providers, hence I would have to pay $1000 in out-of-pocket expenses because the anesthesia bill was higher than what they are allowed to pay.

I called them up to figure out what was going on and was kind've shocked at what the CSR said. The explanation was that even though the hospital is within their network, the anestehsialogist was not, hence they have some percentage they will reimburse, but it's not 100% covered. She encouraged me to deal with the hospital and get them to accept just the insurance company payment.

Is this typical of what I should expect? I feel like my insurance company is trying to pull a fast one my not reimbursing my expenses at a provider they should be reimbursing. I don't like the fact they are encouraging me not to pay (I didn't get a hospital bill yet), when they should provide coverage. At the same time the CSR was painting the anesthesialogist as the bad actor since he wasn't part of the hospital, but she mentioned this was typical.

Sucks for me since all of my costs are supposed to be covered when I go to an in-network hospital per my insurance plan, although getting an epidural was my wife's choice and not ordered by a physician (like I want her to endure the pain though!). Has anyone gotten a bill reduced by talking to the hospital?

[ldysknzfn1]

I'm no expert...but I know around here (Norfolk,VA) physicians(no matter the specialty)can be kind of like "free lance" doctors if you will. Which means that the hospital will use those guys b/c they don't have to pay their malpractice insurance premiums...those guys pay their own. We have several groups like that around here. One is called..Tidewater Emergency Medicine Physicians. These guys come in and fill in shifts in the ER or sometimes man the ER's w/o hospital support..just interns or residents...you get a separate bill for them along w/the hospital bill. So your anesthetist may be a part of a group of physicians that fill in or give the hospital support and it's cheaper for the hospital that way. I would think they should have told you that before hand..but if that's all that's available to their patients..you have to take what they have on duty.

[Burgundy&Gold4Ever]

I encountered the same thing. My 2nd child wasn't breathing when he was born, and the respiratory specialist -- or whatever that person's title was -- was considered out of network. I forget how the matter was resolved, but I think we had to pay it at out-of-network rate. Insurance stinks! (My child is fine. He didn't breathe for the first 45 seconds, but then they got him breathing. There was no long-term damage).

Congrats on the birth of your child!

[Tastes Like Chicken]

Congratulations- and yes I too was ****ed by health insurance this past year with my health issue and subsequent surgery. I have insurance, pretty good insurance according to some, and I'm still over $2k in the red for stuff that my insurance wouldn't cover.

Health insurance is a ****ing pathetic joke.

[Sebowski]

I've heard of Doctors reducing bills to just accept the insurance payment.

[The Sisko]

Fergasun, my advice would be to make a royal pain of yourself. If you agitate long and loud enough by making/writing multiple calls/letters, asking for supervisors, and ultimately going to your state insurance commission, you may very well get out of it. If you're not willing to take the time and/or effort, you'll probably end up paying the extra $$$.

One thing working against you is that with the recent drop in the stock market, I expect insurance companies (which typically invest part of the $$$ they get in premiums in the stock market and other investments) to get a lot tighter with claims payments. OTOH, you have something infinitely more valuable than $$$. Count yourself lucky for that much.

Good luck. In some ways, health insurance really is a huge gyp.

[JMS]

Sucks for me since all of my costs are supposed to be covered when I go to an in-network hospital per my insurance plan, although getting an epidural was my wife's choice and not ordered by a physician (like I want her to endure the pain though!). Has anyone gotten a bill reduced by talking to the hospital?

Sucks to be all of us. You got off lite. But you do have options here. First thing take a deep breath, and get good and mad. Your insurance company does this sh|t because they figure you will pay the bill rather than fight. Every day they can deny you is money in their pocket. Clip a thousand dollar from 20,000 patients and soon it adds up to real money. Embrace your anger and don't let the ****s win... Your anger will sustain you!! Here is your game plan...

1. Get help Your doctor, hospital business office, and employee benefits office can be a lot more powerful than you are. Talk to them and get them involved.
   
2. Contact one of the Non-profit groups such as The Patient Advocate Foundation, which employs many case managers to help people work out insurance issues. These guys really know their stuff and can work miricles, although they typically are more motivated by the extreme cases. 100k or more... believe me they're out there too. But they'll help you out too. There are also a number of for profit groups which will help you fight your insurance companies. Try the non profits first.
3. Be persistent Appeal again and again and again. You may go through three or four levels of appeals before you get a favorable resolution.
   
4. Use the right words Certain words will trigger a denial. For example, sometimes insurance companies refuse to pay for surgeries related to cleft lip or palate, saying it's not medically necessary. When parents appeal saying the child needs the surgery for "cosmetic" reasons or to "enhance esteem," the appeal often fails. Appeals that mention problems with "biting," "chewing," or "swallowing" are more likely to work.
   
5. Ask your doctor to try again Often a tweak in paperwork will change everything. For example, My kid took one drug for two purposes: It improved the effectiveness of his chemotherapy, and it helped his anemia. The insurance company refused to pay for it as part of his chemo. When the doctor re-filed the request mentioning anemia, it worked.
6. You may need a lawyer Steps one to five will often work, but in the end, the threat of a lawsuit (with lawyers cc'd on a formal letter is what really shows you are a serious person). It's a last resort.. But depends upon your insurance. Many insurance companies are sheilded from lawsuites and everyting goes to state omnibudsman... Consult a lawyer.

The most important tool a patient can have is the will to keep going, The Patient Advocate Foundation (non profit mentioned above) helps patients appeal tens of thousands of denials a year, and claims those denials are reversed 94 percent of the time. once they get involved.... There are a lot of these groups out there which will work hard on your behalf.

It's the willingness to fight intelligently and make yourself a pain in the ass which is what will get you covered.

You might want to check out the movie Sicko too. It's a real education.

[JMS]

Bumping this because I think I had some pretty good advice..

[Zguy28]

Congratulations- and yes I too was ****ed by health insurance this past year with my health issue and subsequent surgery. I have insurance, pretty good insurance according to some, and I'm still over $2k in the red for stuff that my insurance wouldn't cover.

Health insurance is a ****ing pathetic joke.

No kidding.

My first child cost me ZERO dollars in 2001. Second cost me $600 in 2004. Third cost me $1200 in 2006.

All on BCBS and from the same hospital and same job.

[IVSkinsFan]

I got the insurance statement from my wife's birth of our second child (I know there will be congratulations, thanks!). On the statement it said that our hospital was out-of-network (I'm fortunate to have BCBS PPO), but I already know the hospital was one of their "preferred" providers, hence I would have to pay $1000 in out-of-pocket expenses because the anesthesia bill was higher than what they are allowed to pay.

I called them up to figure out what was going on and was kind've shocked at what the CSR said. The explanation was that even though the hospital is within their network, the anestehsialogist was not, hence they have some percentage they will reimburse, but it's not 100% covered. She encouraged me to deal with the hospital and get them to accept just the insurance company payment.

Is this typical of what I should expect? I feel like my insurance company is trying to pull a fast one my not reimbursing my expenses at a provider they should be reimbursing. I don't like the fact they are encouraging me not to pay (I didn't get a hospital bill yet), when they should provide coverage. At the same time the CSR was painting the anesthesialogist as the bad actor since he wasn't part of the hospital, but she mentioned this was typical.

Sucks for me since all of my costs are supposed to be covered when I go to an in-network hospital per my insurance plan, although getting an epidural was my wife's choice and not ordered by a physician (like I want her to endure the pain though!). Has anyone gotten a bill reduced by talking to the hospital?

Same thing happened to me when my wife had our second girl. Wife got an epidural, come to find out the anesthesialogist was not a prefered provider. Had to pay him $750. Was I supposed to ask him when he came in to give the meds or what.

[twa]

Bumping this because I think I had some pretty good advice..

I hadn't heard of the PAF...thanks,I'm sure I'll need it with the wife's surgeries.