<rant>

So, my wife is pregnant and had a pretty severe gallbladder attack about a month ago. We ended up in the hospital for 3 days, and we went to the hospital that her doctor, who is covered by her insurance, works out of.

We got the bill today and our insurance didn't cover a single bit of it because the hospital is out of network. That is just so annoying to me. Now I'm on the hook for thousands of dollars that I didn't expect to be paying.

Our doctor is "in-network" but not her hospital?

They couldn't have mentioned something to us when we were being checked in at the hospital?

I went from being under my parents > Navy > VA Disability so I've never dealt with health insurance and admit to be ignorant about it. However, this is just ridiculous to me. :-)

</rant>
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I Work In Health Care, Brother. Sorry, But It's Probably Going To Get Worse.:-)
We All Should Check With Our Physicians Before Undergoing Any Treatment In Order To Determine If Our Insurance Covers That Particular Operation Or Procedure. I Would Call The Hospital & Try To Work Out A Monthly Payment Plan. Hospitals Are Usually Willing To Negotiate. Good Luck!:-)
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In addition to what Greg mentioned, you have the right to appeal your insurance carriers "denial of benefits." Your wife was under the care, custody, and control of her primary physician, and needed to go where he/she is admitted to practice.

I do believe that your wife's doctor can, and should, go to bat for her in this matter, and maybe this would help in a favorable decision to come from the insurance carrier.

You may also want to look into your State laws/regulations regarding insurance carriers too. Bad faith law suits are something the insurance carriers try to avoid (especially when it comes to television and newspaper exposure).

Last resort, and only a last resort, would be to pass this by a good law firm that is versed in this area of neglect by insurance carriers.

Good luck brother...:-)
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Unfortunately, you should have checked the policy before the emergency occurred. You can lay this squarely on the hospital. It's not the doctor or the insurance company. For whatever reason (usually the hospital doesn't like the amount of reimbursement) that hospital opted not to accept the insurance. Happened to me a couple years ago. Company switched plans. My doctor accepted the insurance, but the hospital he uses did not.

Double check with the insurance carrier. They may reimburse to you some percentage of the bill for using an out of network provider.
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Yea it was my fault for not checking really. And I am sure the hospital will work something out. Just a pain in the ass ya know?
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Hope that some of Mark's suggestions above can help you out.
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My sister has been going through the system for over 2 years now, a lot of cancer drug trials and complex situations, she has had really good experiences dealing with the patient advocates in the hospitals as well as her insurance company, you might be surprised what they can do for you. It's a lot of calls and people to deal with but there are people that care and can help, when you deal with them jsut remember they aren't the ones that are personally billing you but they are the ones that can help, just keep your frustration in check, they know how to work the system to you advantage.

Best of luck!
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Joe, not really your fault. Your wife was pregnant and suffered a "severe gallbladder attack." That's equal to an "emergency" period. In an emergency situation, many of us are thinking about our loved ones. The last thing on my mind is, "hey, hold on a second doc. I need to check my 60,000 pages of policy in my filing cabinet at home," or "bring up my insurance carriers web page and hopefully I can find what the eff I need on their most likely confusing site." Because insurance carriers pay morons to make it difficult for you to find information, etc. on their web sites.

Your doctor carries much power when he/she is in the ER with the insurance carrier, and probably should of been on the horn with them to speak about this delicate situation where he is admitted to practice. So, don't blame yourself or kick yourself in the pants. Take a deep breath, relax, and get it worked out.

As you can probably see, I despise effing insurance companies. They'll hose you any chance they get:-)
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Hope it all works out - good ideas here -
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In dealing with my wife's numerous doctors, specialists, oncologists, radiologists, phlebotomist, labs, anesthesiologists hospitals, etc. NEVER assume that just because your "covered" "in network" doctor is going to send you to another "covered" "in network" whatever. We've learned the hard way that due diligence is always required. Not only do the doctors (and most likely their administrators), no matter how well meaning, have really no clue about the complicated insurance process, but the actual insurance companies are continually changing the parameters.

Sorry for the added stress this puts on you, but definitely appeal and fight. The squeaky wheel gets greased once in a while :-)



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This as well. We have been fortunate in that Holly's oncologist has a social worker on staff that is really good and knows the system. Not only has she been a real asset in keeping the insurance under control, but she has been able to help us apply and receive several assistance packages.


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And no, it's really not your fault. As consumers we shouldn't HAVE to know the system inside and out. Unfortunately, the reality is that if we do not keep up with our own business, chances are something will slip through the cracks. Lord know, I know a heck of a lot more about breast cancer now than I ever, ever wanted to know. But, even with good doctor's there have been times I have had to step in and say "hey, wait a minute..."

SMH...


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Thanks for the info, Steve. I'm really sorry for everything you guys are going through and hope things are going well!
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One of the things that happened to my sister mid chemo drug trial was the hospital associated with the test was in network when it started but the insurance company dropped a bunch of hospitals and her's was one of them, she even tried changing exchange policies, in the end she had to fly to Texas for chemo and scans ever couple weeks, then her local onc was told by insurance that they wouldn't pay for them to give my sister a shot every week, so they would pay the 2200 for the shot (2200 every week!) but not like $100 for the office visit and someone to give it to her so they shipped the syringes to her house and yup she had to give it to herself. Insurance campaniles are rediculous.
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I once had an intern check me at hospital that was in my network, but the intern was not. The intern sent me a big bill which I was not going to pay and did not have.

After that, I was telling a co-worker going into kidney stone surgery to ask everyone who comes in his room what insurance they take. Made him extra nervous.

If our current regime continues, it's going to get a lot worse and more expensive.
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If the doctor participates in your plan, and is on the staff of the hospital, the hospital has to participate also so you should file a complaint with your state insurance department on this issue. It's not your fault, but the fault of the hospital
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:-)
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Not sure where you got this info, but, no, they don't.

I assume we're talking about a private insurance provider.

Insurance reimbursement is based on negotiations with the individual providers. Usually those negotiations go like this:

Here's what we're willing to pay for these services this year. Take it or leave it.

The provider can either accept the payment, or decline. If they say no, they essentially decline any payments from that insurer. Here in Western PA the two biggest health care providers also each own their own health insurance providers. Needless to say, they won't take the other's insurane. So you have to go to the hospital who owns your health insurance provider.

I didn't mean to imply that you should have checked policy on the way to the ER. This is something you should have checked when you were issued the policy. I agree that these policies contain a lot of legalese, but the covered services and in-network providers are usually easy to find.

Again, double check with your insurane carrier. Some policies will provide some reimbursement for out of network providers. It may only be 40-50% of the total bill, and they usually send you a check rather than pay the provider. But it is some relief, and the hospital will usually work with you for any balance.
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