Health Ins Rant - Chicagoland Sportbikes
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post #1 of 13 (permalink) Old 07-10-2004, 05:14 PM Thread Starter
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Health Ins Rant

I think I can probably straighten this out, but I was wondering if anyone had experience in dealing with this...
Anyway, on my 6/12 accident, the insurance payment info is coming in. they are covering stuff at the first hospital at 100% (it's out of network), but at the second hospital that I was airlifted to, they're only covering 70-80%(it's also out of network). Basically, there were no in-network hospitals that could have taken care of my injuries in the area. I am going to try and follow the appeals process to get this straightened out, but I was wondering if anyone has been through a similar situation and could give me advice.

Here's what just really pisses me off:

The insurance is supposed to cover 100% for emergency purposes whether it's in-network or not. How did my moving to the Madison hospital miracuously improve my condition to make it not an emergency? Also, they expected me to be contacting insurance and doing all this crap when I can barely think on the 12th. How the hell am I supposed to do all that crap?

Anyway, thanks for listening and any advice you have. I hope I can get them to work with me otherwise, I'll be out a ton of $
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post #2 of 13 (permalink) Old 07-10-2004, 05:21 PM
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Aside from dealing directly with your insurance company and assuming your coverage is provided through your employment you may want to contact your Human Resource (HR) person and see if they can do anything on their end.

Be persistent with whoever you deal with.
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post #3 of 13 (permalink) Old 07-10-2004, 05:50 PM
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Re: Health Ins Rant

Quote:
Originally posted by pitbull76
How did my moving to the Madison hospital miracuously improve my condition to make it not an emergency?
Welcome to the healthcare nightmare!

I'm no expert, but I believe that once you were stabilized and your life was no longer threatened, the emergency nature of the situation was over.

You probably need an attorney for this! Welcome to the reason health insurance is so complicated and expensive.

This is a good example of why someone you trust to be healthcare power of attorney is important, and they must be informed about your coverage to make proper decisions when you cannot. One potential issue: was there another hospital that you could have been sent that is in your plan and able to perform the surgery?

You should review all your other policies to see if some of the out-of-plan expenses may be covered another way. You may end up eating the out-of-plan portion of the expenses.

I would venture a guess that many people are not nearly as well covered as they believe when this kind of thing happens.

Dave
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post #4 of 13 (permalink) Old 07-10-2004, 05:53 PM Thread Starter
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Re: Re: Health Ins Rant

Quote:
Originally posted by BusaDave
Welcome to the healthcare nightmare!

One potential issue: was there another hospital that you could have been sent that is in your plan and able to perform the surgery?

No, there wasn't. My plan only has Illinois hospitals as in-network. It was explained to me that the nearest hospital in my network was too far to be transported. That's why this is such bs.
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post #5 of 13 (permalink) Old 07-10-2004, 06:43 PM
 
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Re: Re: Re: Health Ins Rant

Quote:
Originally posted by pitbull76
No, there wasn't. My plan only has Illinois hospitals as in-network. It was explained to me that the nearest hospital in my network was too far to be transported. That's why this is such bs.
Complain to your employer that they have cheap coverage.

You get what you pay for. Sounds like your employer uses a HMO. I CHOSE this coverage when I worked in Illinois because it was cheaper and I rarely get sick. Most of the PPO's offer better coverage but they of course cost more.

It's BS to you, but it's the way the HMO's make money. The HMO's negotiate (leverage) prices for services at certain hospital networks only. Outside of those "networks", the service rates can be 2 or 3 times more, so they make you flip part of the bill.

THis type of negotiating is the same reason drug prices are lower in Canada. THe drug compaines aren't gouging Americans, it's actually the Canadians that are leveraging lower pricing and as a result the companies are forced ot charge hgiher prices in the US to reach their ROI targets.
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post #6 of 13 (permalink) Old 07-10-2004, 06:50 PM Thread Starter
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Actually, it's PPO, but they are a pain about in vs out of network. HMO is worse. Anyway, from reading my policy, I should be able to get them to cover at least some of the stuff at 100% because there wasn't a network facility close enough that could handle my injuries (basically my broken femur). I think part of the problem is miscommunication and lack of communication. I'll follow the appeal procedure, and if that doesn't work I may have to see a lawyer.
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post #7 of 13 (permalink) Old 07-10-2004, 06:56 PM
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I'd start to line up an Insurance Attorney.

Also, be prepared fight the hospital when the insurance does not pay the bills...They love reporting deliquesces to the three credit bureaus.

-- Matthew --

"I'm just a simple man trying to make his way in the Universe" - Jango Fett
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post #8 of 13 (permalink) Old 07-10-2004, 10:12 PM
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You also want to look at how your treatment and medications were coded. Sometimes they can be recoded and legitimately be covered.

Dave
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post #9 of 13 (permalink) Old 07-10-2004, 10:58 PM Thread Starter
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Quote:
Originally posted by BusaDave
You also want to look at how your treatment and medications were coded. Sometimes they can be recoded and legitimately be covered.
Thanks for the idea, but most is coming up covered... just at 70-80% instead of the usual 100%. I think (and hope) that most of it can be cleared up because there was not a network hospital within at least 150-200 miles of the accident that could have worked on my injuries. Basically, the first hospital told me I could either go to La Crosse or Madison to get treatment. Neither one is in-network. The way I read the plan documents, they should cover at least some of it at 100%. They may determine that after x# of days, I could have been transferred to Illinois, but I'll see what I can do there. If upon appeal they still won't budge, it'll be time to see a lawyer.
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post #10 of 13 (permalink) Old 07-11-2004, 06:04 PM
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I'd check your vehicle coverage as well. Do you have medical coverage on your vehicle? When I crashed, I didn't know about the medical coverage on the bike until about 2 months later. Check your statement. You'll know if it's there, it's expensive! My $5000 medical coverage was $60 per six months, compared to $15/mon for similar coveage on the car. The two companies have to negotiate, but generally your vehicle coverage pays first, the other company second.

Check the insurance company's website too. A lot of times they don't keep very good track of who exactly is in network. Also, some type of statement from the doctor saying the airlift to THAT hospital was necessary might make your case a bit stronger.

Good luck. I think I've FINALLY got everything worked out with my accident, and that was last August.

-Chris

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post #11 of 13 (permalink) Old 07-11-2004, 06:43 PM Thread Starter
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Quote:
Originally posted by Grover


Check the insurance company's website too. A lot of times they don't keep very good track of who exactly is in network. Also, some type of statement from the doctor saying the airlift to THAT hospital was necessary might make your case a bit stronger.

Good luck. I think I've FINALLY got everything worked out with my accident, and that was last August.

-Chris
I'll definitely try to get a statement from the doctor(s) st the first hospital for the formal appeal. That should help my case. Thanks.
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post #12 of 13 (permalink) Old 07-12-2004, 09:06 AM
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Typically, you need to inform the insurance company or administrator within a certain amount of time after you are admitted for an emergency.

But the main thing to do is document every time you talk to someone - get the time, date, and name of person you speak with, and what they said.

And you may also be able to have it recoded to get in-network emergency rates. I know when I had an MRI done, I was referred by an in-network doctor and had it done at an in-network hospital, but they sent it to an out-of-network place to be read and it took me several attempts to get it recoded as in-network.

Not only that, when I had a routine ear doctor appointment, it took them months to straighten out the fact that the doctor had the wrong mailing address on file to send the bill to so that I wouldn't get "you didn't pay your bill" letters.

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post #13 of 13 (permalink) Old 07-12-2004, 09:39 AM
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I've dealt with this before. It's going to depend on who you get when you call the insurance co. I've called them up and explained the situation and how what they wanted me to do was not a reasonable option. They understood and covered it. My boss just had a situation where somebody out of network came in to take care of his wife during a surgery. Turned out because they had no control over that since she was sadated and couldn't choose the doctor at the time, the ins. co covered it anyway.


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