An ER visit, a $12,000 bill — and a health insurer that wouldn’t pay. (wages, compare)
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Per the article, Anthem wants to limit ER visits in the four named states to :
The Anthem letter goes on to list “stroke, heart attack, and severe bleeding” as examples of medical conditions for which ER use would be acceptable.
But according to Medline these are the guidelines:
There's a disconnect here - with "severe pain" listed as reason for an ER visit as is "trouble breathing" - that an earlier poster said led to a denial for their child even though one hospital transferred the child to another hospital.
Real disconnect here.
All insurance is regulated at the state level. This was true before the ACA and remains true in a post ACA enviornment. No two states have the same regulations beyond the Ten Essential Healthcare benefits. The ability for an insurer to define medical emergency is one of the variables.
Dont forget most E-room docs refuse to be in network, even when the hospital IS in network. AKA how to get a $1400.00 bill for 10 minutes of work or less. We got a bill for my wife from a doc we never saw, apparently he looked at a chart or something.
Dont forget most E-room docs refuse to be in network, even when the hospital IS in network. AKA how to get a $1400.00 bill for 10 minutes of work or less. We got a bill for my wife from a doc we never saw, apparently he looked at a chart or something.
Could be you saw an associate, maybe a PA who is managed and watched over by the doc. The doc in the background reviews all the data, and eventually signs off on it all. He might have to pay the PA.
I think we let the accepting ER docs decide. If the patient came in with abdominal pain and the doc ordered a CT scan right then and there, that should be considered emergent. Here's a bentyl call your doc in the morning is probably not.
Anthem can save money by training their patients to use their urgent care more often. But it won't happen overnight, maybe a year to get the word out. The urgent care facility can always refer up to the ER if deemed necessary.
Many hospitals contract out ER Physician Services. Whether the visit was medically necessary or not could be the difference in getting paid, or not, no?
Some states have given insurers broad powers to define medical emergency. Not all plans cover medical expenses incurred by insured parties, when traveling abroad. That alone could disqualify a claim.
Yeah, what in the **** was provided that costs, or is any way in the realm of reality, worth that kind of money?
Our healthcare system is a disgrace.
When I had my first child 20 something years ago, they had the "24 hours and out" policy. Meaning, if there were no complications with mother or baby, you left the hospital in 24 hours. I had an easy delivery, they kept the baby in the room with me the whole time for ME to change and feed, then released us the next day, and the bill was some hugely inflated cost even back then. Fortunately, I had a job that had halfway decent insurance coverage. Really, all the doctor did was give me some good drugs and cut the umbilical cord.
I could have stayed at the nicest, ritziest hotel in town, had room service delivered to my door, hired a nanny to take care of the baby, and just used a midwife, and some good drugs, for the three hour delivery, and come out WAY cheaper than what the insurance company was charged for the crappy hospital room.
The problem is NOT that people lack insurance. It is the obscene cost of care and profiteering that has been, and is still going on!
Most deliveries do not require an MD, let alone an OB/ Gyn in a hospital.
Use of midwives and birthing centers, instead of hospitals, is common in Europe. Having one supervising OB/ Gyn on site is far more cost efficient than dozens of MDs independently assisting deliveries. It is one of the many strategies employed to control costs.
More than half of all births in the US are billed to State Medicaid systems. I believe it is approaching 75% in some states. Poor people have substantially higher fertility rates than non- poor. This is a global fact and socialized healthcare is not a factor.
Last edited by middle-aged mom; 02-05-2018 at 08:47 AM..
Per the article, Anthem wants to limit ER visits in the four named states to :
The Anthem letter goes on to list “stroke, heart attack, and severe bleeding” as examples of medical conditions for which ER use would be acceptable.
But according to Medline these are the guidelines:
There's a disconnect here - with "severe pain" listed as reason for an ER visit as is "trouble breathing" - that an earlier poster said led to a denial for their child even though one hospital transferred the child to another hospital.
Real disconnect here.
Anthem doesn't have to follow Medline guidelines. What happened here is that Anthem got approval for this in four states that are notorious for lack of oversight of insurers. It's unconscionable, they are paying claims based on the diagnosis not the symptoms that caused the person to go to the ER and this is part of the argument against allowing insurers to use the rules of one state for policies sold across the US, if they could then I'm sure this policy would be nationwide.
What this means is that if a person presents with chest pain even though they might have a history of heart disease, if it turns out not to be a heart attack they won't pay, and I'm sure they will be very subjective in what they deem "severe bleeding"
As I said, free markets don't work for complex and serious disease like cancer.
It doesnt work for anything really except some extremely standardized medicines or procedures, but even there, most "consumers" are pretty much clueless and it causes providers to just charge whatever they can get away with. It just ends up with almost all providers charging the same high rate for even standardized stuff. Trying to compete on price isnt really profitable and its all about the profits, not about making people healthy. Our health care system is sick and the remedy is to join the rest of the civilized world and guarantee health care as a right for all Americans, regardless of the size of their wallet!
The medical bill is not the cost, and is not what the hospital will accept as full payment. The itemized medical bill is directly inflated to get the most from payers. And in most cases the amount accepted will be substantially less.
For instance a $12K ER bill might be paid off by Anthem for $2K. And if you don't have insurance you can take the time and effort to probe their low end and have them reduce the total charge.
lol
As you know, what a hospital bills an insurer is not what they agreed to be reimbursed by the insurer. When international costs of a procedure are compared, the initial amount billed in the US is often used as a baseline, instead of what the provider contractually agreed to and was actually paid. Why is this?
The difference shows as a contractual reduction on the patient's statement of benefits.
I never understood why the provider bills more than it contractually agreed to be paid.
Many hospitals contract out ER Physician Services. Whether the visit was medically necessary or not could be the difference in getting paid, or not, no?
Some states have given insurers broad powers to define medical emergency. Not all plans cover medical expenses incurred by insured parties, when traveling abroad. That alone could disqualify a claim.
These are all parts of the ER docs assessment of whether to take on the job/contract or not. Most docs during their career have had to or voluntarily take no payers to some extent.
It may or may not be outrageous, but most likely will be settled for a lower number.
For instance my wife's total trauma and related bills for our 1/1/17 crash was over $1.2M. Her Obamacare paid about $300K in total, and the bills are settled.
I'm a doc and I think her care and all they did was worth WAY more than $300K.
And the annual cap on her out of pocket costs, including deductible, was $7k and change.
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