<p>Well, you’ve put the most positive spin on your rotten day that I can imagine - congrats on the ‘chin up’, and good luck w/the insurance bill.</p>
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<p>I’m convinced that some of them do this, after having several rough experiences. I’m getting tired of it.</p>
<p>Happy birthing day Binx! 25 years? God bless. I hope things get better for you and the insurance thing is resolved.</p>
<p>So sorry to hear about your bad day - but at least you have something to celebrate today - Happy 25th to you and your son!.</p>
<p>I do agree with Treetopleaf though, you were definitely able to see things in a good light. Good job putting a positive spin on your crummy day. I hope it all works out in the best way possible for you.</p>
<p>I found that hospitals can be your best ally in these situations, as they have an interest in getting paid. We’ve had a bunch of ER claims denied (I have a lot of active kids) for stupid reasons and I think all have been appealed successfully; maybe the doctor who saw her would write a note; there must be something in the chart to say she fainted.</p>
<p>hey binx: </p>
<p>the Diagnostic code for fainting (or its more fancy name ‘Syncope’) is 780.2. Ask the ER why they did not file under that code, in addition to influenza…</p>
<p>People, people, people. Not a good plan to tell ERs what Dx code to use. 780.2 falls under the “general and ill-defined symptoms” and may not be covered under “emergency services”. There are better ways to handle this.</p>
<p>I’m with Bluebayou, although I don’t know the ICD-9 code, BB. Sounds like they didn’t code for syncope - I hope in the heat of the moment your D or friends emphasized to the triage nurse that she had fainted in the bathroom.</p>
<p>Oh and Binx, you are great. My son 16 year old got rear-ended a couple of weeks ago, and the woman who hit him got out and started screaming at him, cursing and yelling. She won, she got DS so upset that he let her drive off. Her car was undamaged - I presume - and his isn’t badly damaged, but still it will probably cost a couple of thousand to fix. She saw this 16 year old kid, and thought I’ll get the best of him, I’ll convince him he did something wrong. When he got home, now in tears, we had to explain to him that he did do something wrong - he let her get away without calling us or the police or getting a tag number. We did the overkill on now it will be her word against his if she chose to report (for the purposes of getting his attention, we didn’t point out that it is the BACK of his car that is hit, and the FRONT of hers, she isn’t going to be calling the police after the fact - can you tell I’m still angry with this ****). Thank you Binx and Binx hubby for being good, decent people.</p>
<p>Binx for right now, stick with the hospital and get them to change the diagnostic code. The miscoded billing is the problem… happens a great deal.
Almost all claim problems I help with start with an incorrect diagnostic code. </p>
<p>To some of those folks here who are all for jumping on the carrier REALIZE the insurance company didn’t generate the diagnostic code, the hospital did. So screaming to HR isn’t an answer. It’s like slapping your daugther for something you son did. Stick to where the problem orginiated. </p>
<p>The hospital is missing information from the admit and you need to talk with the treating physican or at least submit the additional information to him/her.
The hospital needs to resubmit or eat the bill. The insurance carrier has to pay (based on plan parameters) to the diagnostic code. There are some state insurance laws involved here. They are required to process each diagnostic claim number the same way (based on your plan parameters ie benefits booklet) imagine them not doing that for a second… chaos.</p>
<p>the other thing folks need to understand claims input is simply entering identifier (group number, individual member #) and a indentifier number or code for provider and then diagnostic codes… enter. on to the next claim. The computer processes each claim by it’s plan parameters, and spits out an eob in one direction a check to the provider in another. A claim goes without human review unless (olddays maybe higher now) over 20k. Otherwise it is not cost effective to process the thousands to millions of claims a day. </p>
<p>That is how a company like ( a large phys theraphy co) can get away with charging $7 for a 2oz dixie cup of ice for therapy and put that automatically on each billing. the company then generates maybe 500,000 claims a day under $500 for phys theraphy and maybe half actually used the dixie cup of ice. So 250,000 x $7 of unused materials claimed means 1.75 million pure profit. </p>
<p>Get the hospital to resubmit correctly and the claim will be reprocessed. Your pressure, if you need to apply it, NEEDs to be directed at the hospital. That’s the right place for it to be. </p>
<p>And this isn’t an issue of national healthcare vs. private… it’s a wrong diagnostic code… Let’s help her get it fixed, then tackle America K? </p>
<p>Binx, if you need help and can provide a bit more detial, you can pm me.</p>
<p>I compare telling the hospital what Dx code to use like telling a car repair place what to do to your car. If you take your car in and say “replace the brake pads” and they replace the brake pads, they have done as you asked, even if they didn’t fix the problem (which might have been, for example, the drums). If you ask the hospital to bill using the syncope code, and you find out the insurance plan doesnt cover ill defined symptoms as an emergency, then you cant really keep going back to the billing dept asking them to play “guess what dx code will be paid”. Believe me, its not a fun game to play. I am not saying that syncope won’t be covered, or that "alteration in consciousness (780.0) won’t get covered-- I am just suggesting that Binx befriend someone in the billing dept, see if that person is familiar with her insurance carrier, and see if he/she knows what codes for these medical episodes might be a covered diagnosis that fits with her dau’s presenting sx, and see if the ER will include that dx. Cangel, I know you are familiar with all this, so you know from whence you speak. I have found too, from personal experience as both the biller and the billee (??) that if the hospital is a small facility (probably so in Oxford, Ohio), the billing dept will be generally easy to work with (to a point). I’ve also found that calling the insu co back a few times until you happen upon a NICE representative who will help you (some will even file the appeal for you) goes a LONG way. I have found that when I offer to write a note of appreciation to their superviser, indicating how helpful they were (when the situation is resolved), they are often extremely appreciateive and extremely helpful. Using the auto accident analogy, as your son experienced, many people yell. Some, like Binx and her H, are nice instead, and it goes a long way.</p>
<p><strong><em>edit</em></strong> To clarify-- I agree that this is a coding issue. I am just suggesting that Binx let the hospital figure out what appropriate diagnostic code will likely be a covered ER service. Better to let them solve the problem then to try to tell them what to do. JMO.</p>
<p>Opie-
I agree that the first (or parallel) line of defense is to try to get the hospital to recode the claim. However, if the insurance policy says it is a noncovered service, or that it clearly excludes certain diagnoses, then the patient is going to be responsible for the bill. And, if the hospital isn’t contracted with that insurance carrier, then they have every right to bill the patient. I have found that the insurance company will pull lots of shenanigans to avoid paying a claim (as many others have said above) and speaking from experience, informing HR is an appropriate and successful thing to do if the claim is being unreasonably denied, and the client has chased their tail trying to get the claim paid.</p>
<p>“I agree that this is a coding issue. I am just suggesting that Binx let the hospital figure out what appropriate diagnostic code will likely be a covered ER service. Better to let them solve the problem then to try to tell them what to do. JMO.”</p>
<p>Agreed. You should provide honest information of the situation to the hospital and with the entire correct information allow the hospital to place the proper di codes.</p>
<p>This stuff is a PIA, but with accurate info and persistence, the patient is usually successful in getting a claim paid. But to add to Opie’s example of overcharges for cups and such, if an insu co. stalls on a claim payment for, say, 3 mos before they pay out (with what appear to be quasi-legit reasons so as to stay within the laws regulating when they must respond to a claim), multiply the stalled payments by many thousands of clients, and that can add up to decent interest revenue for the insurer. Also, if only 1/2 of patients challenge a denied claim… thats a lot of $$ kept in the insurers pockets. I had a client once who had an anxiety disorder. He was a claims rep-- whose co paid bonuses to reps for denied and stalled payments. Disgusting. Absolutely disgusting. Needless to say, my client had ethics. He quit that job and went to work for an ethical co. Anxiety sx resolved.</p>
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<p>opie, although I agree that this part of the discussion is better held in another thread, my point in even a passing reference to it in my earlier post was, that, had it been my D who had the experience at an ER while at the University of Toronto, it wouldn’t have been a problem. We never would have heard anything about it and we certainly wouldn’t be presented with a bill for hundreds of dollars. We also would not be in a position to be fighting with someone to have the visit covered, or trying to figure out how to get a coding/billing issue resolved. You’re covered for ER care, regardless of what your ailment is and regardless of how the hospital billing department codes the treatment.</p>
<p>Back to the issue at hand for Binx, I hope you are able to solve this issue easily with the involved hospital. It seems that it might be easier to go that route than attempting to deal with the insurer. Best of luck.</p>
<p>“speaking from experience” Same here. 20 years. </p>
<p>“the insurance policy says it is a noncovered service, or that it clearly excludes certain diagnoses, then the patient is going to be responsible for the bill.”</p>
<p>I need to ask you Should all medical services be considered an emergency after 5? Wouldn’t you agree that some parameters have to be set to allow bedspace for people with real emergencies?</p>
<p>(now, this statement is not about Binx’s situation. A person passed out is an emergency situation the comments above are not specific to Binx’s situation)</p>
<p>Most health plans have definitions of what consitutes an emergency. That is why most plans cover emergencies the same just about everywhere worldwide. In Binx case, I think some key information may be excluded that might change the result, maybe not. That is up to the attending to decide. </p>
<p>“if the claim is being unreasonably denied”</p>
<p>yes, fine but shouldn’t you first make an effort to correct the hospitals problem? You jumped in immediately as if the carrier did something wrong without any knowledge if they had. </p>
<p>In the 20 years I’ve been doing this it is rare the carrier did the wrong, but then I only use quality companies that provide good customer service.</p>
<p>alwaysmom, that is why we have a different tax system than you. Most americans aren’t willing to pay what you do and the canadian business does for healthcare. </p>
<p>If I am paying 50% of my income to the government, I too wouldn’t expect a problem. However, outside of the last few oil rich years, has the canadian system operated without problems? I spend alot of time in BC and when the looney was like the peso and not like the Euro as it is now, I don’t know if what is being said today would still apply. I recall pages of problems with the healtcare delivery system (at least in BC) in the vancouver and victoria papers. It’s a matter of timing when government revenues are high so are services, as they should be.</p>
<p>Hey Binx, so sorry to hear about your friend. But, glad to hear that your daughter is okay. And good luck with the insurance bill. It is a pain, but you can convince them to cover it, I think, because it should be covered. Gee, if someone I didn’t know passed out in front of me, I would call 911. </p>
<p>And the car, too. Wow. I can just imagine how embarrassed the young girl must have been. </p>
<p>So, dare I ask, how has today been?</p>
<p>Opie, the Canadian system is run provincially and I’m not familiar with the BC system. In Ontario, oil revenues have no impact on what OHIP covers. We’ve lived here, off and on, for 30+ years and, yes, a visit to an ER has always been covered. Changes in coverage through the years have been relatively minor, in our experience. I don’t think I’ve ever said that the system is without problems, but a situation such as the one binx described would not be one of them.</p>
<p>I agree that Americans are not willing to pay the taxes necessary, as Canadians are. I’ve said that in many posts on this subject! :)</p>
<p>the big things I was reading as little as five years ago was the limiting of MRI machines in the Vancouver area, not every hospital was going to be allowed to have one. Doctors/nurses strikes. Availibility of services. A couple years ago sitting in a hotel hot tub with a bc bush doctor who really questioned my S entering into med school and supported my D becoming a vet and moving to bc “because vets make far more money than mds in BC” 
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<p>That mid canada oil makes a big difference for the whole country. Revenues are spread as that was one of the last articles I read while vacationing in Victoria. </p>
<p>I married me a canadian and love that side of the family. Plus decades of rugby and soccer…</p>
<p>opie–gotcha beat. 27 yrs of experience in this field from my end. Not going to argue with you. You handle it your way, I’ll handlue it mine.</p>
<p>I do understand the limitations of the insurance company. I remain frustrated with the insurance folks, just for not being able to answer my question in a straight-forward, understandable manner, or explaining to me up front what my options are. My form says to call for information, but when I call, they just read me the form I have in front of me! Why do I have to beg?</p>
<p>I also still think it’s silly to base payment on the diagnosis, which is what was repeated over and over to me: “Your plan clearly states that flu is not an emergency.” (We’re looking all over the website, but having trouble finding where it says that. Might be clearly stated somewhere, but it’s not obvious.)</p>
<p>I appreciate all the opinions and advice. I’m in a holding pattern at the moment, until I hear back from the hospital. I had mentioned to the billing person at the hospital that the fainting episode wasn’t noted in the codes. She was nice, but it was not her problem. She says I should include it in my appeal. Since she suggested having ER review it, I’m hoping that someone there will think to amend it. I’m betting that I will end up having to write the appeal, at which time I may come to some of you for help.</p>
<p>Meanwhile, my D has sent me a nice, coherant account of what happened - albeit second hand, since she was out of it for part of the time. I will send that with the appeal, if necessary. Hopefully the insurance company has leeway to accept that something is an emergency, even if the worst of it is over before a doctor ever sees her.</p>
<p>And yes, today has been better. Several of my piano students even practiced. :)</p>