When a HMO Won't Pay for a OON Emergency

[Northeast Agent]

I'm still waiting to hear back from my upline before I proceed. I need to find out if the determination for "under observation" was made by the carrier or the hospital. She was only in for 16 hours.

If I don't hear from him by EOB today, I'll help the client fill out the carrier appeal form. If no satisfaction there, then we will go to Medicare.

 

[ICACharleston]

I think the thread title "OON Emergency" is wrong from the start. In an emergency, there is no network. And if a member is admitted to an OON hospital for Emergency Care, he must be transferred to a network facility as soon as safely possible.

I hope someone will enlighten me if I am wrong here because I tell clients "the world is your network in an emergency". Ambulances are required to bring emergency cases to the closest facility that can treat them, without regard to networks.

 

[Northeast Agent]

I titled it before I learned the issue really seems to be that she was "under observation," instead of "admitted." And no ambulance was involved. The ER was down south and her home HMO is way up north.

 

[FLM2]

I titled it before I learned the issue really seems to be that she was "under observation," instead of "admitted." And no ambulance was involved. The ER was down south and her home HMO is way up north.

It shouldn't matter one bit regarding the payment of the claim. Your client believed it was an emergency and she needed care so she sought treatment at the closest hospital.

A consumer can't be expected to know the difference between a true emergency and symptoms that are just passing. The HMO is wrong in this and if this isn't covered then how can anyone believe that any claim would be covered with this company?

 

[somarco]

I need to find out if the determination for "under observation" was made by the carrier or the hospital.

Hospital makes that determination by the way they code it.

 

[Northeast Agent]

Somarco, what would your approach be then, since the hospital coded it? Appeal the carrier first or see if the hospital will fix it? Thanks.

 

[somarco]

The hospital won't change the coding. They decide whether to admit (regular) or admit (observation) based on the pts condition.

The issue is why the carrier STILL denied the claim just even though the pt was still treated as an outpt.

Observation is the same as ER. Both are outpt care. One is short term (in and out) the other can go longer.

You need the carrier EOB to decipher. Then compare with plan wording.

Sman provided verbiage (post #7) but not sure it is from your clients BX plan. The PA Blue language may be different. I believe what he posted was from "a" carrier that offers an HMO plan.

 

[sman]

Sman provided verbiage (post #7) but not sure it is from your clients BX plan. The PA Blue language may be different. I believe what he posted was from "a" carrier that offers an HMO plan.

That is correct Bob. I would assume the OP has a copy of the EOC for the plan in question and can view the wording. I'll go out on a limb and say it's likely very similar to the wording I posted.

 

[Northeast Agent]

Somarco and Sman, thanks very much. This gives me something to work with now to begin the appeal.

 

[alexwat31]

thank you very much all for the great conversation..