Suggestions for Appealing Health Insurance Reimbursement

[Anonymous]

I am seeking guidance from those who have been there and done that! I had an emergency surgery for a broken bone a few months ago at Suburban Hospital. While the doctors in the ER and the anesthesiologist were all in-network for my FEPBlue (BCBS) insurance, both the surgeon and assistant surgeon are "out of network." At the time of the surgery I was on massive amounts of morphine and dilaudid. As such, I didn't even think to ask if they were in network or not. Unfortunately, right now the insurance is only covering about 30% of their total charge. I appealed once and they increased the amount from 20% to 30%. This still leaves me on the hook for several thousand dollars to the surgical practice (UGH!). I am planning to further appeal this, but am hoping to get some good guidance from others. Any ideas, suggestions, tactics, good language to use, etc.?

Thanks!

[Anonymous]

bump

[Anonymous]

I don't have any direct advice, but you might want to call the Maryland Insurance Commissioner's office to see if they can help.

[Anonymous]

First of all, what insurance do you have? BCBS Federal Basic or BCBS Federal Standard?

Second, a few things don't sound right. How do you know the doctors in the ER are in network? One FEPBlue site, it should list a facility as in network or not. Is the hospital where you had the surgery done in network? If it is, then I believe they are supposed to cover the surgery.

Either way, they cover it at their usual contracted rate, so the surgeon can still bill you for the remainder. It's called balance billing, and if the surgeon isn't in network and doesn't have an agreement with the insurance company, then it's legal.

If balance billing is your issue, then you might be ahead to contact the surgeon and assistant surgeon and negotiate a rate with them.

But seriously, there are so many variables that affect the situation. You need to read your policy carefully.

It also matters what state you are in. Of course, BCBS Federal is a national plan. But the billing practices of the facility has to conform to state laws.

[Anonymous]

I'm 15:01. I would add that in Maryland, there are some protections against balance billing for HMOs. But these do not apply to FFS plans.

BCBS Basic does not cover any out-of-network providers. But they state in their policy that emergency situations are covered. HOWEVER, I imagine that the provider can still bill you the balance (the difference between what BCBS pays for X procedure and what the provider bills for X procedure).
(and they state that if the facility is in network, then anesthesiologists, et cetera, are covered.)

BCBS Standard covers a portion of an out-of-network provider. But they only cover a portion of their contracted rate. Balance billing can happen.

[Anonymous]

Anonymous wrote:First of all, what insurance do you have? BCBS Federal Basic or BCBS Federal Standard?

Second, a few things don't sound right. How do you know the doctors in the ER are in network? One FEPBlue site, it should list a facility as in network or not. Is the hospital where you had the surgery done in network? If it is, then I believe they are supposed to cover the surgery.

Either way, they cover it at their usual contracted rate, so the surgeon can still bill you for the remainder. It's called balance billing, and if the surgeon isn't in network and doesn't have an agreement with the insurance company, then it's legal.

If balance billing is your issue, then you might be ahead to contact the surgeon and assistant surgeon and negotiate a rate with them.

But seriously, there are so many variables that affect the situation. You need to read your policy carefully.

It also matters what state you are in. Of course, BCBS Federal is a national plan. But the billing practices of the facility has to conform to state laws.

Hi - Thanks for the detailed response. We have FepBlue Standard. According to the website, Suburban is within network. The issue is the balance billing, which is definitely legal, but I am hoping that I can get insurance company to cover more of the surgery than they are doing right now. Thanks again for the input!

[Anonymous]

Anonymous wrote:

Anonymous wrote:First of all, what insurance do you have? BCBS Federal Basic or BCBS Federal Standard?

Second, a few things don't sound right. How do you know the doctors in the ER are in network? One FEPBlue site, it should list a facility as in network or not. Is the hospital where you had the surgery done in network? If it is, then I believe they are supposed to cover the surgery.

Either way, they cover it at their usual contracted rate, so the surgeon can still bill you for the remainder. It's called balance billing, and if the surgeon isn't in network and doesn't have an agreement with the insurance company, then it's legal.

If balance billing is your issue, then you might be ahead to contact the surgeon and assistant surgeon and negotiate a rate with them.

But seriously, there are so many variables that affect the situation. You need to read your policy carefully.

It also matters what state you are in. Of course, BCBS Federal is a national plan. But the billing practices of the facility has to conform to state laws.

Hi - Thanks for the detailed response. We have FepBlue Standard. According to the website, Suburban is within network. The issue is the balance billing, which is definitely legal, but I am hoping that I can get insurance company to cover more of the surgery than they are doing right now. Thanks again for the input!

Well, you might have success at getting the surgeon's practice to accept a lower amount. A bird in the hand is better than two in the bush. So if you call the practice, explain the situation, and express that you are appealing with the insurance company, they may feel inclined to negotiate a lower rate in order to get you to pay sooner without having to wait for some lengthy appeals process with the insurance company.

Another suggestion: Find out the billing codes for the surgeon and assistant surgeon. Find out directly from the insurance company what they pay for those codes. Perhaps even call around to in-network providers who do that same surgery to confirm that the negotiated rate the insurance company is quoting you is in fact the rate they pay out. There are so many glitches that occur in insurance billing. It's possible that the codes listed for the procedure you had done are inaccurate, and they are actually paying out a lower amount than they normally would.

These are just a few suggestions.

I would also get some documentation from the hospital that it truly was an emergency situation -- i.e. you were not in a position to wait to have the procedure done or to go to an in-network provider. It might give you some leverage. Just a thought.

Best of luck.

[Anonymous]

Just because suburban is in network does not mean that all surgeons and anesthesiologists are. You have a PPO not an HMO. An HMO would cover all involved if the facility was in network. You need to read the manual, I believed that I read that you can state your circumstances for an appeal - meaning , you had no choice but to use the doctors on call. Asides from the balance billed by the out of network docs, it sounds like BCBS is providing the correct coverage for your Standard plan.

[Anonymous]

And also, a provider that is I'm network with your insurance cannot balance bill you per their contract. Only a provider that is not part of your network can do that.

[Anonymous]

Anonymous wrote:Just because suburban is in network does not mean that all surgeons and anesthesiologists are. You have a PPO not an HMO. An HMO would cover all involved if the facility was in network. You need to read the manual, I believed that I read that you can state your circumstances for an appeal - meaning , you had no choice but to use the doctors on call. Asides from the balance billed by the out of network docs, it sounds like BCBS is providing the correct coverage for your Standard plan.

Have you had experience with this? I'm not OP, but I'm considering switching from an hmo (fed plan) to BCBS PPO Basic. And this is the one thing keeping me from making the leap.

(sorry, OP, not trying to hijack your thread). But every time I see discussions of fed plans, everyone seems happy with BCBS Basic (federal). But then I saw OP's thread, and it got me worried.

Even though I've had an HMO, I've never had emergency surgery. My problem with the HMO has been that they find a reason not to cover procedures, even when they pre-authorized them. And I have to argue back and forth to get it covered. And I hate that.

But I always have felt safe with an HMO b/c Maryland has some legal restrictions against balance billing with hmo and covered procedures. But I've never really heard if anyone has had any experience with this.

All of the fed HMO rates seem really high, except for Carefirst POS option, but I can't tell if that *counts* as an HMO, so it might not have the same protections. I'd love to reduce my premiums with BCBS Basic, but I'm afraid of both the possibility that they won't cover out of network emergency stuff (even though they are supposed to cover emergency stuff) and the balance billing issue.

I wish people would come forward if they had either issues similar to OP with BCBS Standard PPO or, worse, not having emergency stuff covered at all under BCBS Basic PPO.

Sorry for the long post. I've posted a few times on different threads (and even started threads) on this topic, because it is really one that keeps me up at night. I might be TTC soon after a recent miscarriage. And if I'm going to have a baby next year, I don't want to take any chances that any possible emergency NICU stuff won't be covered or will result in enormous balance billing issues.

Thanks, OP, for letting me borrow your thread. I really hope you're able to get them to reduce the bill. This balance billing issue as well as emergency providers who don't take insurance is really something that needs more attention from our representatives. I don't think it was dealt with in all of the ACA stuff. And as important as I think it is to get more people insured, that doesn't do much good if even the insured can be slammed with unexpected huge bills in situations where they had no choice in the provider or procedure being done.

[Anonymous]

I've had two experiences with hospitals and out-of-network providers. The first time, a member of my family had an appendectomy, and the surgeon on call who operated ended up not being in network for our PPO plan. I talked to the insurance company on the phone, and wrote to them, explaining the situation and that we had no choice over who performed the surgery (which was an emergency). We never had to pay anything to the surgeon, except our normal copayment. In the second case, I had to have a procedure and the only physician group who did that procedure at my hospital was not in-network; again, I contacted the insurance company (in this case, Carefirst PPO), explained the situation, and they took care of the bill, with me again just owing what my copay would have been if the doctor had been in-network.

[Anonymous]

22:56 I had Carefirst Point of Access HMO high option for the last 2 years through feds. Never had any problem with coverage. Ive had 4 surgeries and have paid only the very small copays each time. I am switching to BCBS Basic only to get national coverage. Also helos that Care first has raised their monthly premiums. But honestly in would have stayed with them. They have been amazing to me.

[Anonymous]

PS - I need national coverage because of some injuries in have that require highly specialized doctors that are not local to the DC area. Good luck !!

[Anonymous]

Call the hospital administrator and issue a formal complaint that the surgeons they are using are out of network with the biggest health plan in the region. You did not have a choice of surgeon in this situation, the hospital chose for you. They need to hear that this caused a good deal of unavoidable out of pocket expense.

[Anonymous]

Anonymous wrote:Call the hospital administrator and issue a formal complaint that the surgeons they are using are out of network with the biggest health plan in the region. You did not have a choice of surgeon in this situation, the hospital chose for you. They need to hear that this caused a good deal of unavoidable out of pocket expense.

+1 It is seriously ridiculous that someone could have what is considered a gold-plated health insurance plan (which the BCBS Federal Standard is, and it has some of the highest premiums among the FEHB plans) and still have all of these out of pocket expenses for an emergency surgery. THIS is what is wrong with health insurance/ health care in America: The reality that you can have excellent insurance with one of the largest health insurance companies with the largest network and STILL end up with thousands of dollars of unexpected costs, and that's just for one surgery. Imagine if someone has a sudden brain aneurism burst and requires multiple emergency surgeries or ends up in a coma. Even though the plans have a catastrophic maximum, the balance billing costs do NOT contribute to that maximum; they are unlimited. And that is ridiculous.

I'm all for getting the uninsured insured, but a good percentage of people who go bankrupt due to health care costs are people who HAVE insurance, and supposedly good insurance at that.

When will politicians do something about this? In a developed country like ours, a person who has one of the best health insurance plans (with high premiums paid by both the person and her employer) should not have to worry that going to the emergency room is going to cost thousands of dollars. It's simply ridiculous.