Am I screwed ??

  1. In a nutshell.....
    I started having CP at work. The doc. I was working with admitted me. To save me time, he admitted directly, instead of through ER. (therefore, not an "emergency").
    The hospital he sent me to was not within my insurance network. I did not know that. And I DID ask the admitting receptionist if my insurance was OK. She asked if it was Medicaid. I told her no. She then said. "It will be fine, I'll put in under commercial" (or something along those lines). So I didn't worry about it and signed.
    Well, now the hospital calls and says I'm responsible for the whole 24 hr. stay. I explained that I had asked both the doctor and the lady that admitted me if it was covered and they both assured me that it would be. The biller on the phone just said "well, utimately it is the patient's responsiblity to make sure it is covered and you will have to pay."
    What else could I have done? Is there any way I can fight this or am I totally screwed ???

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    About EndoRN

    Joined: Nov '00; Posts: 100; Likes: 3
    RN-GI Endoscopy


  3. by   sunnygirl272
    my advice, for what it's worth: be noisy and fight, call your insurance company...have the doc who admitted you write a letter...
    Your only screwed if you allow it, Fight like he** with your insurance company and with the Facility you went with. You also may wish to go the extra mile and go through the bill with a fine tooth comb , and reduce the bill with the usual unwarented charges... Then call and harrass your insurance company until they give in , they may not cover the entire amount but they will mostlikely cover the majority of it. Did you go throught the ER of that hospital if so then you should be automatically covered if you have a major medical and Er comprehensive coverage. Fight with them and dont give in, with any chest pain entrance it is considered ER coverage.
    Good luck
    ps: direct admits are Emergant cases as well dont let them slide you into the pile of that crap either if they Dr can justify your admittance than your covered under the Emergant care.
  6. by   renerian
    Usually with chest pains and MVA the closest center is covered. try aclling your insurance plan and ask them if they just need a letter from your dr. or something. I think you would win that on appeal.

  7. by   RNCM
    Emergency care is just that - emergency!
    All plans have some benefits for out of network facility use if it is emergent (OR IF THE PATIENT PERCEIVES IT TO BE EMERGENT). I would get your benefit plan summary (your benefit booklet) and look for provisions that apply to emergency care.
    APPEAL APPEAL APPEAL. You should be able to get it taken care of.....Buena Suerte~!
  8. by   TCW

    I work for an insurance company handling benefits so I see this type of stuff on a day to day basis. As long as the claim was submitted with a diagnosis of chest pain it would fall under the category of emergency. You can file an appeal to have this reviewed by your insurance company's complaints/greivances department. Make sure you get as much information you can regarding the incident and include it in your appeal. Be as specific as possible.

    I know you were told that ultimately it's your responsibility to determine if something is covered or not, but under emergency situations that's not normally advised.

  9. by   susanmary
    Can this be covered under your worker's compensation?
  10. by   KaraLea
    Um, OK...The next time I start having CP, I'll be sure to stop and take the time to make sure that the nearest hospital is covered...APPEAL, APPEAL, APPEAL.
  11. by   EndoRN
    Thank you everybody! Thank you, thank you, thank you! I did, indeed, recieve a bill for 2,300 !! I sent it to my MD with a letter pleading for HELP! He called the insurance co. and they are going to pay it ALL !! Yahoo !!!

    Much relieved (and free of CP) !!
  12. by   sunnygirl272
    that's fantastic!!!

    and how are you doing????
  13. by   shygirl
    Yeah! It really does pay to stand up for yourself!