Parents Negotiating ER bills?

[COz]

Holy crap!!!! Sorry, I have zero advice. I knew health care was expensive in the U.S. I just didn't realise how much!!! Woah!! All of a sudden glad to be living in a country with free ER visits... I'd be broke!!

Remember this when the election comes up (Australia)...

 

[Aussiemum75]

That's crazy so glad Australia has Medicare.

 

[Aussie_coach]

Here in Australia treatment in the ER is absolutely free. If you stay in the hospital and need surgery it's free. Well it is paid for through our taxes anyway.

 

[profmom]

Okay totally off the subject but next time just tape it to the next finger and call it a day....

Hahaha, remembering the sighing and eyerolling from DS's coaches last year when he broke his pinky, was put in a splint, and was sternly instructed "no gymnastics for six weeks" . . .

Happychaos, while I don't think the ER should be used in lieu of a primary care facility unless there are no reasonable alternatives, when a young child breaks a bone outside of normal pediatric/orthopedic practices' business hours, an ER trip is warranted and should be covered by insurance. In fact, around here if we had gone to our pediatric practice, they would have sent us to urgent care if it was open or directly to the ER anyway.

 

[flippin out]

Best advice... have accident insurance for the kiddos. I personally am a health insurance broker and I have a high deductible. But we have accident insurance to cover just that type of instance. I haven't needed to use it yet (knock on wood). I would suggest a payment plan with them I hope she is feeling better.

I have kids in several different sports and accident ins is a must for us. It has paid out more than it has cost to have (premium) every year. I highly recommend having it to anyone that has kids participating in sports (club and school both).

 

[wallinbl]

For other American citizens and residents on this thread, check into the coverage you have before you explore supplemental insurance. Ours is very good for accidents (though allegedly it sucks for cancer), so we'd be wasting money picking up a supplemental policy. We've now been through three broken bones in the family in the past five years, and I don't think we paid more than $200 combined, which included three months of biweekly PT for DD.

Ours pays out regardless of out of pocket costs or health coverage. If health insurance pays 100%, I still get a check from the accident insurance. I sometimes like to joke with DD that I made money on her elbow break.

 

[flippin out]

Ours pays out regardless of out of pocket costs or health coverage. If health insurance pays 100%, I still get a check from the accident insurance. I sometimes like to joke with DD that I made money on her elbow break.

That is how outs works also.

 

[profmom]

I've got a daughter who's been on team for 5 1/2 years and a son who's been on team for 3 1/2 years. In that time, the two of them have each had one broken bone and DD has been to the orthopedist twice for Sever's, and almost all of the costs have been completely covered. (DS the eldest has never had a soccer injury requiring a doctor's visit. He got his broken bone in a bizarre pep band incident.) Payouts from supplemental insurance would have to be pretty large for these four incidents to balance off the premiums I'd have been paying over the nine years, which would be even longer if I included my oldest child. Insurance is so complicated and varied in the US that it makes a lot of sense to look carefully at your own policy, but just be advised that if your insurance has good coverage, supplemental insurance may not be a wise financial choice. The companies are, after all, selling a product on which they expect to make a profit.

The balancing tips in the other direction depending on how poor your coverage/how high your deductible is for accidents, how accident-prone your child is, the relative injury rate at your gym, and the level at which your child is competing. I'm not against supplemental insurance, but I don't think it's a no brainer for everyone. I am glad that several people have had good results with it though!

 

[my4buffaloes]

I would definitely call. We were charged months later almost $500 by the hospital that did my dd's X-rays, MRI, casting, etc. We called our insurance company and then the hospital. The insurance company has a set amount they will cover for things and were showing that we had paid everything we needed to pay and that the hospital was only allowed to charge up to a certain amount for the procedures.. When we talked to the hospital they were trying to bill us the difference of what the insurance caps it at and what they want to charge. Our $500 bill was erased as soon as we called the hospital on it. They are not allowed to charge you the difference. But that doesn't mean they won't try.

There are so many things it could be, but even if it takes you several hours to get this straightened out it will be well worth your time to argue this.

 

[MAcastsalot]

I believe that "balance billing" (charging the patient the difference after insurance pays the negotiated rate) is legal in a few states, so depending on where you are, you may be stuck with the bill. I would start by calling your insurance company. The hospital billing office is going to try to get as much money as they can out of patients, so even if it is illegal in your state, they may keep billing you until you push back. Here is a chart I found while dealing with balance billing for my own ER visit. It is from 2013, so there may be updated regulations in some states since it was published. http://kff.org/private-insurance/st...iders-balance-billing-managed-care-enrollees/

 

[wallinbl]

I believe that "balance billing" (charging the patient the difference after insurance pays the negotiated rate) is legal in a few states, so depending on where you are, you may be stuck with the bill. I would start by calling your insurance company. The hospital billing office is going to try to get as much money as they can out of patients, so even if it is illegal in your state, they may keep billing you until you push back. Here is a chart I found while dealing with balance billing for my own ER visit. It is from 2013, so there may be updated regulations in some states since it was published. http://kff.org/private-insurance/st...iders-balance-billing-managed-care-enrollees/

Without getting too deep into details, be careful what you infer from that page/chart. "Managed care" and "balance billing" in that context have specific meanings that may not necessarily be apparent to the patient/policy holder. It's becoming less and less common to be under a policy where this would apply. In most cases, you are on the hook for the difference between the negotiated rate and the coverage amount (note that the insurance doesn't always pay 100% of the negotiated rate; they may pay 0%). Your best bet is to read your Explanation of Benefits (EOB) that the carrier sent you for each claim. If you think you're getting screwed by the provider, your insurance company will help with that. If you're getting screwed by the insurance company, contact your state.

 

[MAcastsalot]

Without getting too deep into details, be careful what you infer from that page/chart. "Managed care" and "balance billing" in that context have specific meanings that may not necessarily be apparent to the patient/policy holder. It's becoming less and less common to be under a policy where this would apply. In most cases, you are on the hook for the difference between the negotiated rate and the coverage amount (note that the insurance doesn't always pay 100% of the negotiated rate; they may pay 0%). Your best bet is to read your Explanation of Benefits (EOB) that the carrier sent you for each claim. If you think you're getting screwed by the provider, your insurance company will help with that. If you're getting screwed by the insurance company, contact your state.

Interesting. I'm not in the insurance field, but every insurance policy I've had has fallen under that chart (both federal health plan from my spouse's job, and through private employers), and we've had to deal with balance billing in 3 different states. I'm not doubting you, though, you clearly are better versed in insurance than I. One thing that I found, though, was that the hospital/doctor's billing group was billing and threatening to send to collections before I even got my EOB. I would think contacting the insurance company first would help clarify the situation.

 

[twinmomma]

Did this happen in the gym? If so, your gym should have insurance that covers any out of pocket costs for you.

Otherwise, holy crap this makes me happy we have Kaiser. DS fell at school and required stitches and it was $50. I saw the full bill, which was about what yours was, but that's only on paper since Kaiser is a closed system.

 

[kimute]

Wow! Thanks everyone for the great input. The main thing I've learned from your replies is that I should keep pushing back. I will call both the insurance company (which I haven't done yet), and the hospital again.

I will also find some urgent care alternatives for the future... We were one week post leaving Kaiser (actually they kicked us out without notice as our self-employed plan didn't qualify under healthcare reform...) for Anthem Blue Cross when this happened so I didn't even have a pediatrician yet.

 

[alr83]

Isthe remaining balance your deductible / co ins? I've done ins billing and where we are, if we further discount (which we should not) what the ins co says is your responsibility we are responsible to contact them and let them know. Then it would get adjusted with them that that amount is no longer applied to your deductible or co ins. Dr's and hospitals sign contracts with ins companies and if they don't follow those contracts can be liable for ins fraud. Check your explanation of benefits from the ins. It will give you more breakdown on what they paid, what was adjusted (assuming you used an in network hosp) and what was your responsibility (deductible / co ins).

Call the ins co with all info in front of you and they can explain it.

 

[alr83]

Also keep for good notes of who you talk to and what it was about.

 

[NMNorskie]

If this insurance is through your employer (or your spouse's employer), contact your HR department and ask for detailed documentation about what the insurance does and does not cover. Read that carefully before you contact the insurance company, so that you know what you're talking about.

How much of this is your deductible versus your co-pay? I have a background in HR, and this seems like an extraordinary large copay...but I can see it being a really big deductible (a lot of them are up to $1,500/year now, even for really good insurance).

 

[Midwestmommy]

That sounds like roughly a $1,500 deductible, a $150 ER copay, and 20% coinsurance......which would be roughly $1,820 out of pocket for that first ER visit of the year. That would usually be an HSA plan. Do you have HSA funds you can use to pay part? The good news is that hopefully the deductible is met for the year. I think the minimum deductible to qualify for an HSA plan is around $1,250. The benefit is that your and employer's contributions to HSA can be carried forward into future years. Only benefits you though if there is money left in the HSA account! (as opposed to an FSA plan where it's use it or lose it each year I think).

If the disallowed amount is due to charges being out of network, etc., then by all means fight it with your employer (if it's an employer sponsored plan). 80% of large employer sponsored plans are actually self-funded (your employer self funds claims and only buys "insurance" for really big claims) and are not traditional "insurance." And the ultimate fiduciary and decision maker in that case is your employer, not the network listed on your card. Push them if they are disallowing a big chunk.... Such as saying the outsourced radiology or something is not in network....

 

[2G1B]

I have several thoughts...

First is on if you take a kid to the doctor or ER for a broken finger. IMO, yes. You do. My son broke his pinky. At first I was like, "Just buddy tape it, he's fine"; but it was really bruising and swelling, so we did go to the ER (it was after 8:00 p.m.). His finger was broken, and it was broken at the growth plate. A friend who is an OT stressed to me how important it was that I make sure his finger was properly treated because up to 50% of you grip strength is in your pinky. Stuff like rings could be pretty darn hard without it! We as parents have no way of knowing if a break is of little concern or if it is at a growth plate, we need a doctor and xrays to determine this.

Which goes into if it is an ER visit or not... Most pediatricians don't do xrays in their offices now. So you have to go somewhere else for that. If you already have a doctor/patient relationship with an ortho then you can just go straight there if it is during office hours; but after hours or for a first break you often have to go the ER or at least urgent care route. For my family, at this point, unless there is an obvious bone deformity, we will be waiting to get in with the orthopedist; but that is because all of my kids are now established patients. But for DS's finger the ER was the right move since it was his first injury, a Friday night and I wouldn't have been able to get him in with a doctor for several days.

As for what is going on with your insurance now... push back. Is it possible that some of that is what you have to pay towards your deductible? A lot of it depends on what your insurance plan is; but it is always worth following up on. I had to go to the doctor when we were out of town recently and at first insurance denied the claim. I spoke to them this week about it and it is now being covered. Always follow up with them. In my experience I first call the insurance company to find out why they aren't paying and then if needed I also call the doctor; but 9 times out of 10 it is handled through the insurance company.

 

[Midwestmommy]

PS "balanced billing" means that your network allows a certain payment (whether negotiated, or out of network) to the provider and pays it, and then the provider then turns around and bills you for the difference. Not because of your benefits (deductibles, coinsurance etc) but because they won't "accept" the rate your benefit plan pays. This happens in some states, but is fairly rare... It's more likely they are saying your benefit plan structure isn't covering certain charges.