Help with medical expenses, insurance, appeals, out of pocket expenses, etc.

We're getting bills. I don't know exactly how all of this works, but so far we've had bills from the first hospital, the ambulance, and the lab from the second hospital. 

Our out of pocket is about $6,500 max for in network Tier 1, and $10k for in network Tier 2. Our first hospital was Tier 1; our second hospital is Tier 2. However, there were no Tier 1 providers with the specialty that we needed in our area--I think the nearest one was about 200 miles away. Additionally, the Tier 1 hospital referred us to the second hospital. Literally said "You can go to 1 of these 3 hospitals, we recommend this one". None of the 3 that we could go to were Tier 1.

My understanding is that we will need to appeal the bills that have come in as denied coverage. Right? Who do we appeal to? The insurance company? Do we appeal right away, or wait until we have more bills?

Also, all of these bills that we're seeing are having insurance applied, but it looks like they're all hitting at the same time and the out of pocket doesn't matter--what do we do? Shouldn't they eventually say 100% covered because we hit the out of pocket max? 

All in all, I think there were about 30-45 MD's involved, at least 5 APN's, 2 genetic counselors, a dietitian, at least 10 respiratory therapists, technically 3 hospitals... And that isn't including the nurses or residents. I don't think this is going to be easy to figure out.

I have had luck in the past calling and talking to my agent, who’s been very helpful explaining how it will all work when Ive had confusing post-hospitalization bills. 

Sorry you’re having to deal with this crap on top of everything else.

Margie

Yeah, unfortunately you have to deal with all this too.  Have the agent on your contacts list.  Get ready for nasty letters and threats.  Ignore them.  Point them to the insurance companies.  The crap will be coming in for a year.  Maybe more.  Just ignore it and call your agents/insurance companies. 

Sorry about everything, mtn.

My random thoughts with no real experience...

Contact your insurer and see if they have a Patient Advocate who can assist with billing.  Best would be if you can gain an inside contact who can get familiar with your complex case and help walk through.  

Contact your hospital either as a patient to get billing help or as an employee (I think you said your wife works there) and see if HR has any assistance offers.

Contact Ron McD House.  They have seen your story before.  Maybe they have resources or have leads to resources.  

Yep, the likelihood that your insurance has figured it out with the hospitals already is slim. You may even re-read some of the 'statements' and see language like "this is not a statement - only for informational purposes" in the fine print. 

If you do get a statement from a doctor or hospital, don't pay yet, especially if it is not showing an actual payment from your insurance. (An 'expected payment' does not count). 

Insurance should always pay first, then you pay. Even if the service was 100% under your deductible or whatever, the claim still has to go from the provider to your insurance, and your insurance has to send a message back saying "this is 100% covered by the patient". Note that when that message is sent back to the provider, the insurance company will also say "oh and by the way, you are to charge the patient no more than our contracted rate for this service". It's that second message that should knock a large chunk off your bill. Again, even if you owe 100% since you haven't hit deductible yet. 

I don't work for an insurance company, so I can't really say from their end, but I would try to call them and see if you can get assigned a case rep or someone who will help see this as one large event rather that 50 separate appointments. 

BTW - when the smoke clears, you can expect statements from at least the following entities (though some might be 100% paid by your insurance when you hit deductible or whatever).

1. Hospital 1
2. Hospital 2
3. Hospital 3
4. Ambulance
5. Anesthesiologist
6. Maybe a doctor if a specialist who does not normally work at the hospital was called to consult

You should not expect to be billed separately for any nurses or residents or providers who saw you during your hospital stay (except as noted anesthesiology for some dumb reason), as they should be covered by the hospital statements. The doctors may have separate charges for their time, but it would be unlikely that they are on a separate statementing system as the hospital they work for - but it can happen. 

Finally - you would appeal to your insurance company if they are truly denying payment. But again, it seems unlikely that the providers know that this fast. You can call the number on the statement as well and say generically "my insurance said they will pay" if you are nervous, but there is plenty of time before the providers will start getting nasty (threatening collections) about the bills. In my experience it is usually a year before unpaid hospital patient statements are sent to collections, and that is only if the insurance has fully completed their part, and the patient has not made a single payment on the remaining balance. 

TLDR - your providers have just started a fight with your insurance (sending a claim), and at this early point they are trying to get you to put additional pressure on your insurance to pay. 

What Robbie said.  It will take a while to sort out but it will get there. Be patient and don’t let any of the threatening sounding letters get to you. It will be very stressful.

One thing I have learned about medical bills: stay in contact, but don’t be in a hurry to pay them. It’s astounding how much money perks through the various insurance machines eventually, and if you’ve already paid those bills, it keeps on perking to someone else. Send in a few bucks now and then, but 90 days old is nothing in medical billing. 

After you have exhausted all efforts through the channels and you have to pay a bill, call the hospital, doctor etc. and ask for a discount. I’ve seen anywhere from 15-35%.

Note: I had an 8k hospital bill that was a result of me using a hospital that was out of my network. I called and told them I could only pay $20 a month. After a year and half the bills stopped coming. That was 7 years ago. 

mtn said:

Our out of pocket is about $6,500 max for in network Tier 1, and $10k for in network Tier 2. Our first hospital was Tier 1; our second hospital is Tier 2. However, there were no Tier 1 providers with the specialty that we needed in our area--I think the nearest one was about 200 miles away. 

The term for this is "network inadequacy." CMS requires your insurance company to have local in-network facilities for each specialty. If there's a real network inadequacy (and CMS gets to determine that), you should get some relief. However, you may run into a situation in which a rural county might not even have some of the rarer specialists, which would let your insurer off the hook. Don't know if that applies to your situation or not. 

As for the bit about hospital 1 sending you to another hospital: Your insurance company will tell you it's up to you to make sure each facility, doctor and specialist you see is in your network. Unless this was an emergency, don't expect them to budge on this point. 

Your grievance/appeal rights depend on the type of plan you have, but you should at least have one appeal directly with your insurer, and another with an independent reviewer.

My wife is in the appeals dept for a health ins. company.   She's out for the evening, but my general impression is to appeal anything that your insurance denies.  I don't know that insurance would have even reviewed and denied at this point, though.    I'll have her read over and report back. 

FWIW, I'm wondering if you're just seeing the initial EOB (Explanation of Benefits) forms.  One anecdote - my son spent several days in a tertiary care hospital and we didn't see an actual bill for over a year.

Stay strong, and focus more on supporting each other than worrying about the insurance!

XLR99 said:

My wife is in the appeals dept for a health ins. company.   She's out for the evening, but my general impression is to appeal anything that your insurance denies.  I don't know that insurance would have even reviewed and denied at this point, though.    I'll have her read over and report back. 

FWIW, I'm wondering if you're just seeing the initial EOB (Explanation of Benefits) forms.  One anecdote - my son spent several days in a tertiary care hospital and we didn't see an actual bill for over a year.

Stay strong, and focus more on supporting each other than worrying about the insurance!

 

Given what I know about insurance, you're probably right. Almost no way their billing has passed insurance. 

We got billed for a piece of medical equipment at the out-of-network rate because the company that our in-network doctor uses was oon.  

I sent a nice email to my insurance company (after calling and asking about it, I was given the appeals email address) and a few weeks later they said they would cover it at the in-network rate. 

Im sure your situation is much bigger than mine but I pray that you have the same or better results 

When our twins were born and spent all the time in the NICU the biggest help we had was a patient advocate. Not only did she help explain alot of things she also helped with contact numbers and even directly making calls herself. It was a huge help for my wife and I at the time. It took 2 years for final billing on everything too come through. The first 3 months we got copies of everything even before the insurance seen them. That's why I know just how staggering the child birth total was.