When a HMO Won't Pay for a OON Emergency

[Todd King]

Read the policy language. Good chance the words "life threatening emergency" or something similar is there.

Note: non-life threatening "emergencies" are generally not covered by insurance, including Medicare

You may need to get into the weeds regarding diagnosis and treatment codes with the billing provider(s) and carrier.

Or else the carrier is being difficult.

Diverticulitis can be life threatening if left untreated.

 

[goillini52]

Diverticulitis can be life threatening if left untreated.

Yep, it almost killed Brock Lesnar.

 

[somarco]

Diverticulitis can be life threatening if left untreated.

That can apply to almost any medical condition.

I was not being flip in suggesting the patient did not have a serious problem. What I was suggesting was to look for ways to appeal with the carrier without bringing in the big guns.

Way too often consumers want to call a lawyer or the DOI when a claim is denied. In most situations the carrier was correct to deny the claim based on the way it was submitted.

Gathering facts and appealing to the carrier and/or provider for a review is simple enough.

Filing a complaint with CMS is another and, in my opinion, is overkill at this point.

Let's dig a bit deeper.

ER waiting rooms are flooded with people who think they have an emergency.

Many don't but they are triaged and either treated, transferred or sent home.

Ambulance's are called quite often for non-emergency events. Those are not covered either.

If CMS get's involved is there any chance the client/patient will say the agent never fully explained medical emergency? Is it possible CMS may want to know if the agent followed a CMS approved presentation?

Just asking.

 

[Northeast Agent]

Thanks, all. I'll take Somarco's advice and get into the weeds regarding diagnosis and treatment codes with the billing provider(s) and carrier before proceeding with CMS.

Wehotex, this is one of the regional "Blues" carriers in PA. I don't want to name them as I don't know if they monitor this board. They were sanctioned last year for a "little pharmacy problem."

I'll post the outcome when this gets resolved.

 

[wehotex]

That can apply to almost any medical condition.

I was not being flip in suggesting the patient did not have a serious problem. What I was suggesting was to look for ways to appeal with the carrier without bringing in the big guns.

Way too often consumers want to call a lawyer or the DOI when a claim is denied. In most situations the carrier was correct to deny the claim based on the way it was submitted.

Gathering facts and appealing to the carrier and/or provider for a review is simple enough.

Filing a complaint with CMS is another and, in my opinion, is overkill at this point.

Let's dig a bit deeper.

ER waiting rooms are flooded with people who think they have an emergency.

Many don't but they are triaged and either treated, transferred or sent home.

Ambulance's are called quite often for non-emergency events. Those are not covered either.

If CMS get's involved is there any chance the client/patient will say the agent never fully explained medical emergency? Is it possible CMS may want to know if the agent followed a CMS approved presentation?

Just asking.

So true. When this has happened, I work through the carrier's Appeal process first with EOC description of benefit, claim info and brief description. If denied at the Appeal step, then I send copies to CMS, the carrier and the member. That way, the member can never say that I don't work hard for the business.

 

[Todd King]

Thanks, all. I'll take Somarco's advice and get into the weeds regarding diagnosis and treatment codes with the billing provider(s) and carrier before proceeding with CMS.

Wehotex, this is one of the regional "Blues" carriers in PA. I don't want to name them as I don't know if they monitor this board. They were sanctioned last year for a "little pharmacy problem."

I'll post the outcome when this gets resolved.

Just curious, but was she in the hospital for more than 24 hours?

 

[ICACharleston]

I believe the benefit of the doubt goes to the "prudent layman" for decisions like this. Since most of us didn't go to medical school , we are allowed to err on the safe side and use the ER.

A VA employee told me they use a Nurse Hotline decision tree that always arrives at "go to the ER".

 

[sman]

A VA employee told me they use a Nurse Hotline decision tree that always arrives at "go to the ER".

You're going to get that response (go to the ER) from most any medical professional. They are not going to risk the liability of telling you not to seek further treatment just off of a phone call.

With that said, I always recommend urgent care over the ER unless it's an obvious ER situation (i.e. - chest pains, obvious compound fracture, etc). Urgent care is cheaper and usually much quicker than the ER.

 

[Todd King]

I believe the benefit of the doubt goes to the "prudent layman" for decisions like this. Since most of us didn't go to medical school , we are allowed to err on the safe side and use the ER.

A VA employee told me they use a Nurse Hotline decision tree that always arrives at "go to the ER".

No, it doesn't go there every time. I use it myself and ended up with appointments to see whatever Dr. that I needed to. Of course, it has come to "go to the ER" as well (when diverticulosis turned into diverticulitis), but not often.

 

[leevena]

I do not necessarily disagree with what has already been said or recommended, but I do have reservations because of lack of complete information. My issue is with the ER and the Admittance. Let's assume that your client did believe that the pain was in fact "emergency" in nature, and let's further assume that she was provided an approval by the carrier for the ER visit. This approval does not extend to a hospital admit.

So, was the approval for the ER or was it for an admit. I realize this may sound like a minor distinction, but it is important.

Good luck with your efforts.
Lee