If you have Medical Insurance and are treated in the emergency room, unconscious by a Dr. who is?

Question

....not part of your network, and get a huge bill a month later? What do I do?

The ins is BCBS-PPO and they did pay some already. I'm guessing the Dr is not a BCBS-PPO provider ?? But they were paid some-can they ask for more??? What Dr. is NOT BCBC participating??? Geeeezzz

It was actually my boyfriend, who went to the ER and ended up with open heart triple-bypass, after a heart attack.

Answer 1

I've seen this situation hundreds of times.

Generally, true medical emergencies are always paid according to your in-network benefits.

However, keep in mind that your insurance company is paying the same amount that they would pay a network doctor. This amount is a discounted amount, not the doctor's full billed charge. Doctors who have a contract with your insurance company agree to write off the difference.

The problem that you're having is likely that the non-network doctor your boyfriend saw *was* paid the same dollar amount that a network doctor would have been. However, because there's no contract with the insurance company, the non-network doctor is under no obligation to write off the difference. They can legally bill you for the whole difference between the network rate and their full billed charges.

I strongly suspect that's what happened to you. And, unfortunately, its unlikely that you can do much about it. You certainly can appeal and request that the insurer consider the full billed charges rather than the network discounted amount. (In fact, I'd recommend that you do that - couldn't hurt to try.) But keep in mind that the insurer is under no obligation to pay the full billed charges and will likely still insist on using the same discounted amount that an in-network doctor would have been paid.

Example - 2 doctors bill your insurance company $500 for the same type of emergency services. One is in-network, one isn't. The network provider agrees to accept $300 as paid in full for the service and write off the $200 balance. The out-of-network doctor gets paid the same $300 as the network doctor, but is under no obligation to write off the remaining $200...you get the bill for $200. But, as far as your insurance company is concerned, the claim was still paid "in-network" b/c they gave the out-of-network doctor the same amount a network one would have received.

Answer 2

Most insurance policies have a provision that there is a fixed dollar amount that you pay for out-of-network ER visits for actual medical emergencies (unless you are admitted to the hospital, in which case the usual percentage applies). If they decide that it was not really an emergency, you may have to pay the entire bill, but can appeal their decision as to whether it was an emergency. Several years ago, New York State passed a law saying that sudden chest pain that felt like a heart attack was a medical emergency for insurance purposes, even if the final diagnosis was not something serious. In any case, if you were still unconscious when you arrived at the ER, the insurance will probably consider it an emergency.

Answer 3

Contact your insurance company first to see if there is a stipulation in your benefits about instances (like you stated in your question) about what additional benefits may be allowed. If your insurance company does not pay the higher benefit, you can either appeal their decision with medical records documenting your treatment, or you can contact the dr. In some cases, they will agree to accept what your insurance has paid.

EDIT:After reading your additional info, definately your boyfriend should contact BCBS and find out how the dr's benefits were paid. If the dr truly is out of network, there may not be much they will do. But certainly, due to the severity of his illness, he had no choice. They may reconsider. It may be that the part they didn't pay is due to a deductible or co-pay. But he needs to ask them!!

Answer 4

As other commenters have noted, most insurance companies do pay for ER services as if you were in network. You should typically not be balance billed.

If you have such a plan, start with the little step. Call the doctor's office, tell them you got their bill and that you have insurance. Have them bill your insurance. If they say the insurance did not respond, or did not respond with the full payment, then call the insurance company. Tell them the ER doctor is billing you while the insurance company should pick up the tab. They will *usually* settle it all directly with the doctor.

Answer 5

Fight with the insurance company. Fight and don't quit fighting. Call the hospital billing office...Remember to be real nice... you want them on your side!! Ask them if they have any advice as to what you can do to get the Ins. Company to pay for this. If that doesn't work.... There is going to be a state level regulatory office that is over all of the insurance companies that operate in your state. (Assuming that you are in the USA) All of this is going to take more time than you probably want to spend on it, but you have to keep your cool, and stick with it!!!

Good Luck!!!

Answer 6

If it was truly a medical emergency, call your insurance company and explain the situation and ask them to reconsider the charges. More often than not, if it was a *true* emergency - and not "going to the ER because I have diarrhea for an hour" kind of case - they will relent.

Answer 7

You will still have to pay for the services. I'd suggest contacting the insurance company first, as many of them have a special clause for an emergency room treatment.

Answer 8

I agree with the others about appealing to the insurance first. If they refuse to pay more, try seeing if the billing office will reduce your bill. Give them a call and see what their policy is.

Answer 9

call your insurance company, if this was an emergency situtation, they will still likely pay their portion. Don't panic, you always get the bills first and then the insurance payment later.

Answer 10

It should be submitted to your carrier as an out of network charge. Then you have to pay it, based on your out of network costs.