A Crummy Day

Parent Cafe
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<p>jym - the insurance co asked me up front if I had “verbal permission to discuss my D”. I said yes. But it struck me that my D is allowed to use my insurance, the hospital is allowed to bill me, and the insurance company is allowed to deny payment – but I may not be allowed to discuss it, and it’s my money at stake. (Don’t at all mean to side-track this discussion. I am well aware of the privacy issues, etc. It just seems odd they would expect me to pay a denied claim without questioning it.)</p>

<p>Fortunately, Miami had a special form up front explaining confidentiality, and “offered” the opportunity to the students to sign waivers. MU seems to think it is a good idea, and encourages students to sign! So we had all that done. Covered medical, academic, etc.</p>

<p>My D does not remember anything of the blacking out part. She has only the words of the girl who found her, and her roommate, who was next on the scene. D had to wait a bit at the hospital, and drank water, etc while she was waiting. By the time she was seen, she was feeling better, and obviously could not give details about what happened, although she did tell them she apparently fainted. I hope they wrote it down! I am hoping they will ammend the coding.</p>

<p>She did not think she had the flu, nor did the doctors. She’d had some congestion, and a bit of a fever several days prior - thought she had a cold. She had decided if she woke up with a fever, she would go to the clinic. But she did not have a fever, so was getting ready for her 8 a.m. class. She seemed to collapse for no reason, except she admitted she felt weak. I think it’s possible she was dehydrated from the previous fever - but since they didn’t see her till after she had a lot of water, they would not have noted that.</p>

<p>The doctors did not initially think she had the flu, but since it was going around, they tested for it. I think they may have been satisfied with the first answer that presented itself, and did not look further for a reason for the collapse. (Which I think now was perhaps dehydration and/or fall of blood pressure for some reason - wild guess on my part - we’ll never know.)</p>

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<p>Hey binx,
Yes, isn’t it grand that the insurance companies, the hospitals, and the colleges/universities can take our $$ but keep us out of the loop due to privacy issues. With my s, I also said “yes” when they asked if I had permission to talk to them about billing. While billing in and of itself isn’t confidential, the billing diagnosis or code could be. For example (and the is JUST and example) what if the fainting was due to an ectopic pregnancy, eating disorder or alcohol/drug use issue? They wouldn’t (rightfully) want to talk to us about that. they just do want us to pay the bill. However, keep in mind that if your dau signed the hospital forms, she, not you, is, in truth, responsible for payment. You could, theoretically, thell them to go to her to address their payment concerns. Not practical, but in truth, appropriate.</p>

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<p>Binx,</p>

<p>Please understand both the entities you are dealing with (hospital and insurance carrier) operate in a heavily mandated environment. The issue about information disclosure is an offshoot of HIPAA, a government generated mandate that both must follow or face fines. It does create some very odd sitatuations. Sometimes government mandates create unpleasant situations that were unintended or unforeseen. </p>

<p>For me, I dislike the fact I can no longer wait with my children when they fly after they go through the screening. They sit for a couple hours while we are left behind a baracade. I’m sure when our government crafted this plan for airport security, they didn’t realize they would be doing this to families. It’s another unintended consquence of what someone thought was a good idea.</p>

<p>Good luck with your situation. </p>

<p>Just one word of caution, please be careful about the advice you receive here.</p>

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<p>I do understand about the privacy thing. As you say, it leads to some strange situations. As jym posted above, a fainting episode could be from a variety of unknown issues, which is why I think it’s important to consider the reasons for seeking care, rather than the after-the-fact diagnosis. (And I think we’re all in agreement that asking 18 year olds to diagnose their friends in advance is less than prudent.)</p>

<p>As some may remember, I have my BS in nursing – we all bring different angles and experiences to things, and that is one of the things I appreciate most about CC. It’s been discussed over and over that an anonymous internet site needs to be read with a certain degree of caution. I am far too independent to take advice blindly! But I do appreciate the opinions and suggestions offered me.</p>

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<p>"why I think it’s important to consider the reasons for seeking care, rather than the after-the-fact diagnosis. "</p>

<p>Agreed. I think you may need to get statements from those who found her and who decided to take her in to submit to the hospital ER. I do think with friendly persistence they will change the diagnostic code that will allow insurance coverage to be applied. As you’ve realized it’s a hospital problem. </p>

<p>Check your plan summary for definition of a medical emergency and include it with your coversation with the hospital. for example mine reads as follows…</p>

<p>The emergent and acute onset of a symptom or symptoms, including severe pain, that would lead a prudent layperson acting reasonably to believe that a health condition exists that requires immediate medical attention, if failure to provide medical attiention would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part, or would place the person’s health in serious jeopardy. ( A prudent layperson is someone who has an average knowledge of health an medicine.) </p>

<p>Under my policy’s definition, your situation could be supported as reasonable. You may also request the chart notes from the visit. You’ve mentioned a couple of things that may have been a little quick in diagnosis, you have a good point to make there. </p>

<p>This is a subject I talk about with my son in med school. As he is going into case studies, I’ve advised him to never walk in with a diagnosis before listening to the patient and never trust your diagnosis until you’ve double checked. The chart notes might help enlighten what was discussed and what was decided. Maybe they were a bit hasty.</p>

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<p>Yes, binx, all of the above suggestions have been recommended to you earlier in this thread.</p>

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<p>Was there a final verdict on whether the HR folks or the Benefits folks are the best first-shot? Is it different for different companies or is there a general rule?</p>

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<p>We’re still waiting to hear back from the hospital, so I haven’t taken any other steps yet. There is still the possibility that this can be resolved quickly and painlessly. (Hope springs eternal…) But we have scoured (I think I posted this, but can’t remember) the website for what IS considered an emergency, and it is not there to be found anywhere. So if we have to appeal, we will probably have to approach HR at the very least to get some sort of policy copy. All we have is the agent’s words: “Your policy clearly states that flu is not an emergency.” [An aside: People DO die of the flu every year!] So we need to figure out what the insurance company needs to hear.</p>

<p>Everyone seems to be in agreement that my D’s situation was handled appropriately by her dormmates. Now we just need to crack the secret code.</p>

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<p>“But we have scoured (I think I posted this, but can’t remember) the website for what IS considered an emergency, and it is not there to be found anywhere. So if we have to appeal, we will probably have to approach HR at the very least to get some sort of policy copy. All we have is the agent’s words: “Your policy clearly states that flu is not an emergency.” [An aside: People DO die of the flu every year!] So we need to figure out what the insurance company needs to hear.”</p>

<p>Binx, this is your husband’s company plan? you should have a hard copy of the plan booklet, HR should have extras and normally they should be distributed every plan year to all EE’s. Some carriers mail them directly, others go to the HR’s office and they distribute. You may be able to find them online, if the carrier offers a secure link. All plans are different, so you may have to look specifically for yours.</p>

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<p>“Yes, binx, all of the above suggestions have been recommended to you earlier in this thread.”</p>

<p>:) gee ok.</p>

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<p>We have both hard copy and online policies outlining our benefits that state (I’m quoting from memory - might not be exact) “emergency room with no overnight admission - covered at 90% after deductible.” Under Ambulance it has a note that it must be a genuine emergency, but there is no similar note about the ER. We can’t find any other statements about ER care anywhere. </p>

<p>That’s not to say it isn’t there. But we spent probably an hour last night going through the website, and couldn’t find it.</p>

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<p>“Was there a final verdict on whether the HR folks or the Benefits folks are the best first-shot? Is it different for different companies or is there a general rule?”</p>

<p>I can offer you my advice, but please understand you don’t have to take it. I seem to have a wee wee match going with someone else here. Follow any advice given on this website at your own risk… </p>

<p>That said.</p>

<p>When you receive an EOB (explaination of benefits) and something is denied, there should be a reason listed on the eob. Call the insurance company’s cust service first and have them walk you through the eob. Let them tell you what they have first. If that’s wrong, let them know that it’s incorrect. They may be able to fix it there or they may not, depends. If it’s supposed to be covered but it’s not, that needs to be fixed. If it’s more than the plan covers and the plan has paid it’s full amount, they’ve done their part. The rest is your responsibility. </p>

<p>Now, if what they tell you isn’t what happened, you may have a code error. If you have a code error you have to contact the provider of service and ask them their reason for coding that way. Again listen. It could be anything from a miscommunication, a tranposed number, a file error or many other things. If they realize they’ve made an error they can resubmit and you’ll get a new eob and it’s done. no worries. </p>

<p>back in the preHIPAA days when I could talk directly with claims. I dealt with a claim that was kicked out as not covered. The EE sent me a copy and I called the carrier. The customer service person on the other end when asked about the eob, stated matter of factly, that “sir, this plan does not cover eye examinations.” I replied…“that’s great, this is for a obgyn exam, I don’t think she can see from there…” “oh, sorry. It was coded as an eye exam. We’ll contact the provider for clairification…” It appeared that two numbers were transposed turning a gyno exam into a vision exam… </p>

<p>Work your way back from insurance carrier to provider first. </p>

<p>If you still can’t get things resloved to what the plan covers(very important point…it’s what YOUR plan covers, not necessarily what you’d like it to.) contact the HR and broker.</p>

<p>You should make the first effort to solve yourself. In these new HIPAA days it is harder for 3rd parties to intervene on your behalf as information is considered confidential. I used to be able to contact practices as well as carriers and fix things pretty quickly, HIPAA now makes that impossible. I now have to walk a person through what to do which is much harder to do. </p>

<p>good luck and remember you don’t have to do what I suggest.</p>

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<p>“We have both hard copy and online policies outlining our benefits that state (I’m quoting from memory - might not be exact) “emergency room with no overnight admission - covered at 90% after deductible.” Under Ambulance it has a note that it must be a genuine emergency, but there is no similar note about the ER. We can’t find any other statements about ER care anywhere”</p>

<p>In your hardcopy towards the back should be a section of definitions…ie A Doctor is… illness is…hospital is… you should have medical emergency and it’s definition there as well. </p>

<p>You may be in the summary section of your plan.</p>

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<p>Hey binx,
No, I don’t think you posted here, until now, your futile attempts to find the insu co’s ER coverage policy on their website (the specifics of the coverage for ER visits usually varies from employer to employer, and are subject to what your H’s employer purchased, so you would more likely find it in the employee manual or benefits website belonging to your h’s employer-- if it isn’t buried in the micetype). That (your futile attempts to find the details) was discussed backchannel, previously, where you also mentioned in greater detail than you posted in the “vent” thread (and I am paraphrasing) how badly you were treated by the insu clerks/reps and supervisors, how you were left on hold for eons, transferred, talked down to, scolded, transferred and put on hold again, talked down to again, etc. with no one, from your description, being kind or in any way helpful. They never answered your questions or told you how to rectify your problem. Thats simply unacceptable. I am surprised they didn’t “accidentally” disconnect you. That happens too.</p>

<p>Hopefully the hospital can resubmit with additional diagnoses. If a patient shows up to have an xray to rule out a broken arm, the diagnosis is “broken arm”, even if the person doesn’t have a broken arm. They can put your daughters presenting symptoms as a diagnosis, especially since she didn’t come in to R/O the flu, but rather to identify the reason for her LOC (loss of consciousness). In the meantime, as you try to do your due diligence , gathering the data in preparation to address/appeal their denial, you have all the more reason to contact HR to find out the answer to the specifics of the policy plans. You also shared (elsewhere) that this is a new insurer for your H’s company (a large, international company). The HR department <em>does</em> want to know if the new carrier is easy to work with or not. They spend a lot of money on insurance, and employee satisfaction is important. Even if you do get this resolved, the experiences you have had with the insurer thus far have understandibly left a bad taste in your mouth. There is no excuse for the lack of courtesy and lack of assistance you have received from their staff. </p>

<p>The person coding your dau’s hospital bill initially probably has no clue about the specifics of your insu plan. While failing to put all preliminary and discharge diagnoses on the bill may have been an oversight, I don’t think it is an egregious error-- and can hopefully be fixed. How you have been treated by your insurer thus far, is , IMO, worse. Keep us posted!</p>

<p>Oh, and to answere DukeEgr, again, from my experience, HR is more helpful in these situations than Benefits. Benefits holds your hand, but isn’t as invested in the process. They manage the plan, but its usually in HR that pays for it.</p>

<p>As an aside, sometimes people think they are in a “wee wee” contest, when in truth they are peeing in the wind.</p>

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<p>:) :slight_smile: :slight_smile: :wink: :)</p>