Doctors/TX Lawyers/Health Insurance Professionals - Help Needed

My wife has type 1 diabetes and the first thing we do when moving anywhere is to find the closest hospitals in network. She requires a lot of care and in an emergency situation, we can’t mess with figuring that stuff out.

She had thyroid cancer and had her thyroid removed in January as instructed by her endocrinologist. It is common to have calcium issues for several weeks post surgery as the body adjusts, but her primary care physician, surgeon, and endocrinologist all instructed us to go straight to the emergency room if her calcium got so low to cause tingling/numbness in the hands, face, and tongue.

We had to go to the ER at our in network hospital twice in the following few days and they admitted her on the second visit. The levels stabilized enough to make an appointment with her PCP, surgeon, and Endo.

We have several bills upwards of $5k in relation the the ER visits. Apparently, the two different doctors that saw her during the visits were both out of network and insurance is refusing to cover it (our out of pocket has been met). The second doctor didn’t even perform an exam of any kind, he simply left the room and called my wife’s endo.

What are our options? How were we supposed to check if the doctors were in network during an emergency visit? Is there any legal backing to help us argue our case?

 

You have to look at your policy. An insurance company can refuse to pay any bill they aren’t required to pay.

Does your policy specify that all bills are paid in an emergency?

A hospitalization is different and not considered the same as an ER visit. All those related charges are treated differently.

The only time you have legal recourse is if your insurance company is not paying what your policy requires they pay.

If your policy states all care has to be in network you are SOL on the bills.
Now you can go to the billing dept of the hospital and many times have bills reduced by 50% if you pay cash or have bills reduced based on income.

You need to work with the hospital more than the insurance company. They need to be coding things properly based on your insurance and type of care. Make sure they are sending everything to the insurance company properly.

 

Ran into a similar situation a year ago with my daughter. Went to the ER, because it was an emergency, and received a $4600 bill a couple of weeks later. We were only there for four hours and no X-rays or MRIs. Now here's the confusing part....the ER is not actually run, or managed, by the hospital itself. It's contracted out to some company that does it for them and when I researched them it turns out they intentionally staff the ERs with out of network doctors. Not sure exactly how it all works but to me it's shady AF. They finally agreed to a MUCH lower amount than what they billed and we paid it off.

 

Yeah you can’t assume all doctors in the hospital are in network. Each provider is seperate and ERs typically are seperate because they are money drains on a hospital. It’s better to run them seperately.

Now you should be able to know what ERs are in network you can go to. They may or may not be the same at hospitals that are in network.

 

Thanks, I’ll go over the fine print again. This is our first ER visit in the 9 years we’ve been together, so not much experience.

Any suggestions on checking for in network doctors in the ER ahead of time?

I feel like I’m being scammed! Did you work with that company or the hospital on the bills?

 

Every single insurance policy is different. Also companies are different. So I’m not sure how your company checks in network providers.

When I had insurance I would just go to the ERs on my network list. It specifically had an ER list. It didn’t state whole hospitals.

I no longer have insurance now. I go where I want, pay cash and get 50% off. My medical care (which is not cheap) is still substantially less than what an insurance premium would be.

Insurance is a legalized scam.
The US healthcare system is a scam. Its all about $$$ and never about people.

I deal with it everyday, its heartbreaking.

 

They weren't that interested in working with me at first so I just ignored all the bills they sent, including the one that threatened collections. They finally sent me one for little less the half of the original and I called my insurance company and went back and forth about them needing to pay more of the claim even though it was "out of network". They finally agreed to pay half of my new total, so after it was all said and done I paid just under $1k. Still too much if you ask me.

 

Just saw this article this morning.
http://www.msn.com/en-us/money/pers...-with-a-dollar7924-bill/ar-AAxGdFW?li=BBnbfcN
Complete bullshit!

 

Found out the ER is in network, but the doctor was not.

We’ve already sent an appeal that was rejected. I sent in a request for mediation to TDI early last week.

 

You can usually ask for the hospital to waive some fees. Get in touch with the financial aid department and ask how much you have to make to qualify. It's a lot of paperwork usually. If you guys make more than 60k a year to 100k a year combined then you guys are probably SOL as far as financial aid goes unfortunately. I just had a surgery that was supposed to be out patient but my heart when crazy the day before surgery was scheduled because I had the condition so long it was wrecking my health, then my kidneys decided to fail after surgery so I spent 5 days in critical care. I'm nearly fresh out of high school and make like 20k a year, so luckily I filed for financial aid and got it all waived except for the testing they had to do before hand (which cost me about 3k in med bills). Without them waiving it I would have owed around 10k, and that's after deductible. Yikes. I know you guys probably already spend a ton on her insulin, testing supplies and meds anyways. I'm a pharmacy tech, and the amount of money some people spend on insulin makes me want to burst into tears. I can't even imagine. Best of luck.
I guess the best news is, if you have to pay it all, set up a payment plan. They report to credit agencies so if you set up a low payment and hash it out for a bit, it'll look good on your credit.