ER Visit-Insurance Claim Rejected

Parent Cafe
1

<p>I haven’t been here for a long time, but I remembered all the wisdom in the Parent Cafe so I decided to post my question here. I would like some of your opinions on an insurance claim for an ER visit that was rejected, leaving me with a bill for $600. </p>

<p>The story:</p>

<p>I woke up with urinary symptoms: particles in urine, which led to difficulty+pain when urinating. I took some samples to examine myself, and while things improved after a few hours, the change was not that significant. I was worried that it could be a sign of a kidney stone about to pass/passing, or some other serious urinary problem. I was concerned that if I ignored this, I could wake up later unable to urinate, and that would be a bad situation. </p>

<p>Since my school’s health center was closed for the weekend, I called up and advice nurse, who told me to go to the ER. My symptoms were troubling, and I thought it would be prudent to see a doctor in case it develops into something serious. So I went. </p>

<p>Fortunately, things quickly improved during my ER visit. By the time I produced a sample at the hospital things seemed more or less normal, and indeed the lab tests came back normal. (Later, it turns out my symptoms were caused by some benign thing.)</p>

<p>This week I received a letter from my insurance company, and they did not cover my ER visit because emergency benefits don’t apply to visits for minor illnesses. They define emergency as whatever a reasonable person believes would jeopardize health, cause death, cause dysfunction of any organ, etc. Now, although my symptoms turned out to be nothing serious, at the time I really thought they warranted seeing a doctor urgently. I didn’t want to wait until it became a really painful kidney stone or anything like that. I didn’t think insurance companies were allowed to reject a claim for an ER visit for something that turned out to be nothing.</p>

<p>Do you think I could make a case that a reasonable person would do the same thing? </p>

<p>One thing that might complicate my situation is my doctor’s notes. After reading them, I realized that when I mentioned my self-samples to the doctor, he apparently took that to mean that my symptoms improved throughout the day. This is misleading, but it’s too late now. I wonder if the people at my insurance company saw that and concluded that I went to the ER for something that was already known to be not serious. I don’t know how much information they have access to.</p>

<p>Is there a decent chance that an appeal letter would change their decision? If so, what should I include in the letter? Should I mention details including my home urine samples, though I have no proof of them? Should I try to wait longer next time something like this happens? </p>

<p>I’d really appreciate any advice or opinions on this. Thanks in advance. </p>

<p>– Troubled Student</p>

2

<p>You’re not a doctor so I don’t see how they can expect you to know what might be wrong with internal organs. It’s not as if you just had a minor cut on your finger. It seems that you might have a shot at an appeal. Try it.</p>

3

<p>It might be worth investing in a medical symptoms book or app and a thermometer.
Did you have a bladder infection? A temperature? Pain in the kidneys?
I think it would be worth appealling especially if you can get the nurse from your school clinic to write a note,</p>

4

<p>Often when you enter a hospital in addition to signing a consent for treatment, you also sign a paper which gives the hospital the authority to appeal to the insurance company on your behalf. Sometimes if the hospital doesnt think the appeal is worth their time they will absorb the cost and you will not owe the hospital anything. I would check with the hospital before trying to argue with the insurance co.</p>

5

<p>I have never heard of that njblue. Have you had that experience?</p>

6

<p>Its worth a shot.</p>

7

<p>Definitely file an appeal with the insurance company. When my son was young, he always got sick when we were on vacation, and invariably at night. He ran fevers … and the claim was always denied. Each time, I appealed. I got paid every time.</p>

<p>When you write your appeal, include the fact that you contacted a nurse help line and were told to go to the ER. If the help line was sponsored by your insurance company (that is, they suggest you call this help line), that is even better … they will have a record of the call.</p>

<p>Yes, also include the details of your home testing. The more details, the better.</p>

8

<p>Yes unfortunately D1 suffered a heart attack at the age of 20. She spent three days in the pediatric ICU. The hospital portion of the bill was over $75,000. The insurance co denied the claim because she didnt tear her aorta or go into cardiac arrest (you cant make this stuff up!!) The hospital decided not to pursue an appeal and I was never billed for any portion of the bill. The hospital did not explain why, but since I wasn’t getting a bill I didn’t push the issue. It’s been a year, D1 is doing fine, taking her asprin daily, but it’s something as a parent still gives me nightmares.</p>

9

<p>" D1 is doing fine, taking her asprin daily, but it’s something as a parent still gives me nightmares."</p>

<p>I can’t help but ask; which part?</p>

10

<p>That sounds really scary, but I’m wondering why they didn’t put her in cardiac care?</p>

11

<p>I agree with mini. I work in health care and the ER visits for nothing are debilitating to the system . BUT how is a non MD/DO (maybe PA /Np) to know if something requires prompt treatment or not? Even if the pt was a dr, sometimes the drs do not know until labs come back etc. … I see pts admitted ALL THE time who wanted to wait until morning to see his/her pcp, or thought er dr would discarge them with a " a pill" and next thing you know pt is going emergently to the OR . … or admitted for a lengthy stay of IV abx for a ton of different scenerios this can happen.</p>

12

<p>Or you could have this boys experience
[Father</a> says Puyallup hospital failed to detect son’s appendicitis - KCPQ](<a href=“http://www.q13fox.com/news/kcpq-father-says-puyallup-hospital-failed-to-detect-sons-appendicitis-20120718,0,4661575.story]Father”>http://www.q13fox.com/news/kcpq-father-says-puyallup-hospital-failed-to-detect-sons-appendicitis-20120718,0,4661575.story)</p>

13

<p>Helpmedic did what s/he was supposed to do: called the nurse. Nurse said go the ER. How was Helpm supposed to know s/he didn’t have an emergency situtation? Helpmedic, call the insurance company back and demand that they pay. State that you are not a doctor, you had urinary pain and saw foreign matter that concerned you, you tried to wait to see if it got better and it did a little but not completely so you called the nurse, and the NURSE sent you to the ER. You have to “fight back” some by bugging the insurance company.</p>

<p>Also, there’s no way the insurance company would pay the $600 quoted you by the hospital. Which is to say if you do end up having to pay, you will be able to obtain a discount from the hospital if you call and try to “work with” them on the billing end. Unfortunately we are at a point with our “best in the world” medical system that if you get a bill, it’s an invitation to a negotiation.</p>

14

<p>I think you have a valid appeal. Don’t back down. You were advised by the nurse to go to the ER. There should be a record of that. You are not qualified to determine if it is minor or not.</p>

15

<p>Of course you should appeal. Send in COPIES, keeping copies of everything for your own files, including a written report of the call you made to the university nurse/health clinic, with a phone number and the name of the nurse who advised you seek ER care.</p>

<p>Many years ago i worked in claims for BCBS, and it was SOP to deny claims that were missing any info, or were at all questionable. Claims processors jobs were not to seek out missing info but to process as many claims as possible each day. If a person resubmitted the claim with the information that had been missing, or with additional information, the claim was given anither look, kicked “upstairs” for a closer look to the review department where nurses/people with the expertise and time to look more closely at claims could give your claim a fair look.</p>

<p>This is one those times when the value of urgent care clinics is of tremendous value. It is worth looking up whether there are any such clinics near your university, and keeping the phone number and address with you. Until 7 years ago there wer NO local urgent care clinics in my wealthy area, and on the occasion of a grandparent visit when she was obviously very ill, needed antibiotics, but not ER visit ill, there was no alternative but to take her to the ER for care. It was a very expensive prescription for antibiotics!</p>

<p>Also, it is worth knowing the basics of your insurance policy. The back of our card clearly states the proceedures to follow in the case of an emergency or if there’s a need for urgent care when we are “out of area”. In our case, we are supposed to self report the ER or urgent care trip ASAP, by calling to report/seek aproval. Never had anything denied.</p>

16

<p>Hugcheck: State that you are not a doctor, you had urinary pain and saw foreign matter that concerned you, you tried to wait to see if it got better and it did a little but not completely so you called the nurse, and the NURSE sent you to the ER.</p>

<p>OP, you should definitely fight it and Hugcheck laid out well what you should say. I would not worry about mentioning those “home tests” because frankly, that’s confusing.</p>

<p>You should also know that you may end up getting more than one bill. Is this from the hospital or from the doctors? Often they bill separately, so there may be more bills for this coming down the pike. And don’t wait - there is usually a fairly small window of time in which you can protest the denial. Good luck.</p>

17

<p>An appeal does make sense. Any chance the organization sponsoring the nurse line that you called has a record of their recommendation? Even if they do not, you can state that you sought medical advice before heading to the ER. I understand that “over-utilization” of the ER is problematic, but it seems you used sound judgement in deciding to go.</p>

<p>For others who may be in this situation later, it could be good to get the name of the organization called for advice and the person you spoke to or “transaction number” for possible future documentation. Good luck.</p>

18

<p>Absolutely appeal. I don’t remember the last time one of my er visits WASN’T rejected. Appealed every time, won every time. Insurance companies try to make money off people who won’t fight them.</p>

19

<p>Thank you everyone for your responses. I have drafted an appeal letter with some of the advice from here. I believe there is record of my call to the advice nurse, so I will try to get access to that today. I also have a copy of my doctor’s notes. </p>

<p>I have explained in my letter that my symptoms improved little over a six-hour period. I really hope that clarifies the doctor’s remarks.</p>

20

<p>Helpmedic-
Keep a log and copy of every appeal letter.
Send the appeal letters with tracking so you know the date that they were received by the insurance company.
Keep track every time you call to inquire about your case.
You should be assigned a case number and refer to it so it will be on record every time you call.
Write a short summary of what you were told in each phone call.
Be persistent, remain calm.
Yes, it is annoying but it is your money.</p>