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Patient Faces Bankruptcy After Ambulance Takes Her To Out-Of-Network Hospital
Consumerist ^ | November 12, 2014

Posted on 11/12/2014 4:46:38 PM PST by SMGFan

Most of us know that it could cost us everything we own if we go to a hospital that isn’t covered by our insurance plan. But what if you’re unconscious and have no say in the matter? That’s the case for a Wisconsin woman who owes $50,000 to a hospital that claims she should just pay up and be happy she’s still alive.

The woman tells WISC-TV [via Reddit] that in Sept. 2013 she went into cardiac arrest and was taken by ambulance to a hospital that was out of her insurance network instead of the one — only a few blocks farther away — that accepts her Anthem Blue Cross coverage

(Excerpt) Read more at consumerist.com ...


TOPICS: Government
KEYWORDS: 0carenightmare; obamacare; obamacareanecdote; obamacarehospitals; outofnetwork
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To: martinidon
Yep, pretty soon this will be your doctor....


41 posted on 11/12/2014 6:47:19 PM PST by dfwgator (The "Fire Muschamp" tagline is back!)
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To: SMGFan

Must be the worst insurance in the world to not pay for out of network emergency.


42 posted on 11/12/2014 6:48:28 PM PST by Mike Darancette (AGW-e is the climate "Domino Theory")
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To: martinidon

Well clearly I had the wrong insurance, because there were doctors and hospitals in and out of my network long before Obamacare showed up.


43 posted on 11/12/2014 6:53:19 PM PST by bigdaddy45
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To: PAR35

http://www.dailykos.com/news/Megan%20Rothbauer

I rest my case


44 posted on 11/12/2014 6:54:44 PM PST by martinidon
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To: SMGFan; bigdaddy45; blueplum; Mike Darancette
The woman tells WISC-TV [via Reddit] that in Sept. 2013 she went into cardiac arrest and was taken by ambulance to a hospital that was out of her insurance network instead of the one — only a few blocks farther away — that accepts her Anthem Blue Cross coverage.

Had she gone to the in-network hospital, she’d only have been hit with about $1,500 in expenses. But since she was taken to the other hospital, she now has to pay the huge difference between what her insurance company paid the hospital and what the hospital charges.

The hospital that treated her billed the patient for $254,000. Her insurance company paid $156,000, which is 100% of what it would have paid to an in-network hospital. That left a balance of $98,000, which the hospital slashed after negotiations with the patient, but still leaves her with bills from individual physicians, the ambulance service and other charges.

Anthem is pointing the finger at the hospital, saying that the insurance company can’t control the prices at a hospital it doesn’t have a contract with.

For one thing, I would like to point out that there is actually a difference in a provider or hospital “accepting” your insurance plan and a provider or hospital “participating” in your insurance plan. In this situation the out of network hospital was willing to accept payment from her insurance company to the tune of $156k but since the hospital didn’t “participate” in her insurer’s plan, they won’t accept the insurer’s in-network fee schedule as payment in full and are therefore free to balance bill the patient for the difference. When you are looking for a doctor, make sure to ask if he/she “participates” in your insurance plan and not merely “accepts” your insurance.

Of all the numerous things to hate about ACA (Obama Care), this is not one of them.

This sort of thing happened long before “Obama Care” and in fact one of the provisions if ACA is that insurers must pay for out of network ER visits, apply to their deductible, co-pays and co-insurance and out of pocket maximums the same as if in-network, were as prior, in some cases, the insurer wouldn’t pay anything to the out of network hospital or pay anything without a pre-authorization, although most would cover at least to the in-network coverage level if the patient truly had a medical emergency, i.e. was incapacitated and taken by ambulance to the nearest available ER even if out of network.

But I also know personally of a few cases where the patient (my brother was one) was taken to the ER via EMT ambulance because at the time they believed it was an urgent life or death situation (i.e. shortness of breath, chest pains) but after the trip the ER and examination and tests, it was found it was something like severe indigestion and not a “true” emergency. The insurance company(s) in those cases refused to cover the ER visit because it was not deemed to be an emergency (but only after the fact) and the patient didn’t call to get a “pre-authorization”.

From Anthem’s website:

Emergency room services – In the event of an emergency, this provision allows individuals to seek emergency room services from in or out of network emergency rooms without pre-authorization for services (post-treatment notification requirements are permitted).

Insurers must cover out-of-network emergency room services, and copayments and coinsurance for these services cannot exceed those for in-network emergency room services. Other types of cost sharing (e.g., deductibles and out-of-pocket limits) are allowed on out-of-network ER if it is the same cost sharing as imposed on other out of network benefits. Health plans must pay the out of network provider the greater of the following: their median payment to in-network ER providers, the amount that would be paid if the plan used the same method for ER as it uses for other out of network services, or the amount that would be paid by Medicare. Members can continue to be balanced billed by the out of network provider.

http://www.anthem.com/provider/noapplication/f1/s0/t0/pw_b148225.pdf?refer=ahpprovider

This is not the fault of her insurance company as they paid as per her plan provisions and contract, exactly what they would have paid for an in-network hospital, but is the out of network hospital playing hard ball with the “balance billing” and not accepting her insurance company’s “in-network” payment as payment in full.

If I were her, I would (or have my attorney) look into what insurance plans this hospital does participate in and what those insurers would pay for the very same services in-network. If those insurance plans with whom the hospital and attending physicians do participate in, pays less than my insurance at the in-network reimbursement, I would tell them, I will only pay that difference. OTHO if those insurance plans with whom the hospital and providers participate in, pay more, I would tell them they need to reimburse my insurance company for the difference. It might not work but I’d tie them and their billing department and attorneys up good and long enough that that they might be willing to negotiate more and bring down that $50k balance to nearly nothing.

45 posted on 11/12/2014 7:00:42 PM PST by MD Expat in PA
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To: martinidon

Didn’t see your ‘facts’ there, either. Now I have to go wash my computer.


46 posted on 11/12/2014 7:02:41 PM PST by PAR35
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To: MD Expat in PA

Thank you for your reasonable and factual response. Obamacare sucks. But not all that ails healthcare is because of Obamacare. And blaming everything on Obamacare only makes us look silly.


47 posted on 11/12/2014 7:09:28 PM PST by bigdaddy45
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To: MD Expat in PA

Thanks - Hospital is being a dick!


48 posted on 11/12/2014 7:12:41 PM PST by Mike Darancette (AGW-e is the climate "Domino Theory")
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To: MD Expat in PA

Geez, what’s with the facts? Nobody wants to hear that. It’s ALL Obama’s fault. Or maybe Hillary.


49 posted on 11/12/2014 7:14:50 PM PST by Wolfie
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To: bigdaddy45
I am not saying there has never been out of network issues. However, it is much more prevalent today. In my 30 plus yr experience with changing insurance plans I have never run across a situation where my current Dr.s or hospital were out of network. We would get these books as big as a phone book with a list of Dr and providers. Today the choices are very limited with Drs. and providers opting out of the obamacare plans.
50 posted on 11/12/2014 7:19:07 PM PST by martinidon
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To: PAR35
Sorry, I probably need to wash mine. Maybe I jumped to some conclusions, but when I read about a young person who lives in Madison WI, , a hot bed of liberals, working with an advocacy attorney my “demdar” sort of like “gaydar” goes off.

Inviting the Daily Kos in to your home pegs the meter.....

51 posted on 11/12/2014 7:26:55 PM PST by martinidon
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To: SMGFan

https://www.healthcare.gov/glossary/out-of-pocket-maximum-limit/

Just a reminder if you get sick away from your network.

The out of pocket max does not apply...


52 posted on 11/12/2014 8:12:52 PM PST by ltc8k6
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To: SMGFan

Cardiac arrest means she was dead. The ambulance had to go to the nearest hospital by law. The ER saved her life. She is upset about her life being saved?


53 posted on 11/12/2014 9:48:47 PM PST by Nota particle (Born yesterday in Biblical terms)
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To: SMGFan
I smell a very winnable lawsuit against the likely Hey Moe. The decision of hospital was not hers to make. There is Trauma Protocol which ambulance dispatchers, paramedics, and hospitals, will all go by. Usually it is the nearest hospital unless that ER is on divert and still I think they take true emergencies. If it's a wreck the Protocol may be take the patient to a level One facility for surgery where a surgeon is either there or will be there is a few short minutes.

The HMO Act written by Teddy K needs repealing. HMO's have all but destroyed affordable care and true private insurance coverage. It became a huge money maker for parent insurers who own most of them. Jack up actual insurance policy cost {which requires covering it's risk} and offer instead a rationing system.

The person was unable to communicate and had she been able to do so under those conditions it would not have mattered. She was going where Trauma Protocol dictated. This system is done to save lives and so the responders and hospitals have an orderly system to go by. There is no corporation I loathe more, none is more corrupt and influences government more than Insurers. Many are corrupt to their very core. I'd go as far as to say over 75% plus of the laws and codes on the books were written solely to lessen the insurers monetary losses.

54 posted on 11/12/2014 10:04:37 PM PST by cva66snipe ((Two Choices left for U.S. One Nation Under GOD or One Nation Under Judgment? Which one say ye?))
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To: cva66snipe

Opps my mistake. His Highness King Teddy’s HMO Bill exempted Hey Moe from litigation.


55 posted on 11/12/2014 10:10:57 PM PST by cva66snipe ((Two Choices left for U.S. One Nation Under GOD or One Nation Under Judgment? Which one say ye?))
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To: SMGFan; All
I know nothing about Wisconsin law, but suspect it is similar to Texas. If so, the poor lady has to do nothing more file a complaint with the state's department of insurance and her claim will be paid.

In Texas, you have a different deductible for out of network services, but once it is met, the insurance carrier must pay (albeit usually with a different coinsurance rate).

However, if the patient has no viable choice for selecting an out of network provider (and an emergency situation is an example commonly cited), then the insurance carrier must pay the claim as though it were in network -- same deductible, co-payment and coinsurance.

Bottom line: Either the lady is incredibly stupid and ill-advised, or there is a lot more to the story than what is being reported here.

56 posted on 11/13/2014 12:43:30 AM PST by Zakeet (Obama: fail ... deny ... blame ... golf ... distract ... lie ... repeat)
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To: martinidon
We would get these books as big as a phone book with a list of Dr and providers.

It's so 1994 to be looking up providers in phone books. Seriously.

57 posted on 11/13/2014 12:57:15 AM PST by cynwoody
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To: MD Expat in PA
When shopping for health insurance, the parameter I look for first is maximum out of pocket. For my current plan, it is $3400 (premium being $51/mo plus Part B).

She was in no condition to sign a contract before her treatment. Therefore, her max should be her plan's maximum out of pocket.

She should transfer any assets she has to her boyfriend and stonewall the hospital!

58 posted on 11/13/2014 1:14:14 AM PST by cynwoody
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To: Monty22002

“Almost every time what the insurance pays is different than what you would without insurance. IE, you get SCREWED”

Indeed. If you pay cash, the thieving, liberal vultures who run these hospitals will charge you 200 to 400% more than what they charge insured patients.


59 posted on 11/13/2014 6:25:15 AM PST by sergeantdave
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