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I had to rush my spouse to the ER on a weekend, we went to the nearest one. I accepted the possibility that it may be out of network and knew it would cost more, but it was secondary at the time.
While in ER my spouse underwent standard blood, urine and CT scan test just to rule out anything serious. Finally, a single shot was needed for stabilization (nothing special, I checked online: it should cost about $150). Most of the time we were waiting in a room, there was a simple saline IV, and we were asked some questions here and there. That's the extent of treatment. We were there until the middle of the night and then they decided to transfer to a different hospital that had a particular doctor. I asked the hospital to release my spouse and that we will get there ourselves, but they insisted on using an ambulance. Quite frankly they made it sound as if they assumed control over the situation and I had no say in it.
At the other hospital my spouse was given a single pill (again, nothing special, maybe a $1), and discharged in the morning after speaking to the doctor. We were simply told to follow up with my spouse's primary care physician. Both hospitals and the ambulance were out of network.
We received a flurry of EOBs, that if taken at face value, amount to $35,000. Insurer participation was less than 20%.
The insurer sent us checks directly. We have so far received only one actual bill from the second hospital, but it's a little vague, showing the full amount but saying that we "may owe it".
We called the providers and our insurance to ask for itemized bills, we are still waiting.
The first due date is approaching. Since the insurance did not interact with the provider but sent me the check, I'm considering paying that amount, plus my co-insurance, along with supporting EOB documentation. Maybe they'll accept it as is, but if they bill us for the rest, I'll insist on seeing an itemized bill and maybe file an appeal with the insurance.
It's frustrating that other than withholding payment, we have no leverage in negotiations. Any astronomical amount is lawful. The sky is the limit. If it's really $35K it would be a serious financial crisis for us.
My question is:
Should we pay what the insurance paid us directly with documents, and only negotiate if they balance bill the rest, or is it better to negotiate first? I worry that if I chose the latter, I implicitly accept the entire sum as a starting point, and I can't say that I have no money because the insurer did send me a check for some of the charges.
As a side note: we found that, even though we are in California, we are not protected from balance billing, because my employer's health insurance plan is based in another state which has no such regulations. California department of insurance can't do anything for us.
I am sorry for your situation. I can not help you on anything.
For balance billing, many health insurance companies have headquarters in other states. Are you saying that if anyone uses any of those insurance, they are not protected by balance billing in California?
Balance billing definition from google:
"That practice, known as “balance billing” the patient ― or “surprise billing” as it is known more colloquially ― will no longer be allowed in California starting July 1. All health care providers in California will have to accept what your insurance company pays them for care delivered in an in-network setting, whether they have agreed to an in-network contract with your insurer or not. California has joined the 20 other states where “balance billing” the patient is no longer permitted."
As a side note: we found that, even though we are in California, we are not protected from balance billing, because my employer's health insurance plan is based in another state which has no such regulations. California department of insurance can't do anything for us.
It doesn't matter where the plan originated for fully funded plans. Your employer can be in Maine and the plan provider in Alaska and you are still covered IF your state of employment is listed as California.
What may be confusing is if your employer is in another state and the plan provider is in another state and it's not a fully funded plan, the employer's out of state location negates California law regardless of your state of employment.
So, it sounds like your out of state employer has a self funded plan so California law won't apply.
It doesn't matter where the plan originated for fully funded plans. Your employer can be in Maine and the plan provider in Alaska and you are still covered IF your state of employment is listed as California.
What may be confusing is if your employer is in another state and the plan provider is in another state and it's not a fully funded plan, the employer's out of state location negates California law regardless of your state of employment.
So, it sounds like your out of state employer has a self funded plan so California law won't apply.
This^^^.
If you are covered by a self funded employer sponsored plan (which most of Americans are) state laws and mandates do not apply. Self funded plans are only required to comply with federal law. They are subject to ERISA ( Employee Retirement Income Security Act of 1974). That is why employers choose to self fund so they can bypass state laws, especially if they have employees in multiple states.
You need to call your insurance and determine:
1) was the claim paid at the in-network benefit level since it was an emergency?
2) was a usual and customary reduction applied to the claim?
3) if so, how much was the u and c reduction?
4) what methodology was used to determine the usual and customary fee allowance (database such as Fair Health, etc)
5) you need to determine how many levels of appeal your plan has either one or two levels and file either o e or two levels.
6)contact your HR department at work and explain you do not understand why the claim was processed this way and you cannot afford to pay the claim. The employer will likely call the broker or TPA to determine what happened?
Medical care is very expensive, especially in California. An ER bill of 35k these days is not unusual. I am an appeals supervisor.
You owe the hospital their full billed charge if that is what your EOB shows. The insurance sent you the check because the provider is out of network -- however that money belongs to the hospital and if you don't pay up they will come after you.
If I were you, I would contact the hospital and find out if they plan to file an appeal and if you can 1) have some of the bill adjusted off or 2) make payments. Most providers will work with you these days. Also sending them their payment shows good faith on your part and they will be more willing to work with you on the balance.
I had a similar experience and ended up in non network ER. I called BCBS and they said I do not have to worry
I never had to pay anything
On most insurance where you have a network of doctors, they pay for out of network if it is an emergency. My husband had a heart attack in another city. We were out of network. Hospital said too dangerous to move to in network hospital 75 miles away. Insurance paid the whole bill-over $100,000 except for maybe $800. The thing is. YOU have to call your insurance and let them know within usually 24 hours that the patient was in ER and admitted. We did pay out of pocket for the follow up with the surgeon until we found a good doctor at home.
My BIL on the other hand ended up in out of network ER because of his cancer his daughter did not think to call. He was transferred the same day to his in network hospital but he received and had to pay $10,000 for his couple of hours in ER before the ambulance arrived to transport him.
The problem seems to be that the medical condition did not qualify as an emergency. It did not require any treatment (according to OP).
The problem with that is that one does not always know if what's happening to them is an emergency or not until after they are examined. That is not an excuse that an insurance company should be allowed to use to deny payment. The current practice seems to discourage people from going to the hospital for fear of huge bills.
The problem with that is that one does not always know if what's happening to them is an emergency or not until after they are examined. That is not an excuse that an insurance company should be allowed to use to deny payment. The current practice seems to discourage people from going to the hospital for fear of huge bills.
Then everyone should go to the ER with a cut on their finger out of fear it could be MRSA? The hypochondriacs of the world would overwhelm the system. Since OP did not wait out of prudence, they are on the hook for the time their case took up for the doctors, specialists, testing, CT scan, nursing care, IV administration, occupying an ER bed, an overnight stay (counts as 2 inpatient days), etc. just to find nothing wrong.
Then everyone should go to the ER with a cut on their finger out of fear it could be MRSA? The hypochondriacs of the world would overwhelm the system. Since OP did not wait out of prudence, they are on the hook for the time their case took up for the doctors, specialists, testing, CT scan, nursing care, IV administration, occupying an ER bed, an overnight stay (counts as 2 inpatient days), etc. just to find nothing wrong.
I knew someone was going to say that. That is not what I was saying though. I'm sure you knew that. Do you not think there is a wsy to get to the middle ground, or do you think only the extremes are possible? Surely there is a way to prevent one problem from becoming the exact opposite problem.
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