Yikes! 2 EE's in a Week, ER Bills Refused by Anthem

[yorkriver1]

ICD-9 is the standard diagnostic coding used by providers and carriers.

CPT-4 is the treatment code.

If ICD-9 is for a sprain then it's a non-emergency in most cases. If it is for chest pains, it is an emergency.

So maybe the coding from the ER/hospital needs to be done differently so the claim rejection for ER to hospitalization claim is not rejected. That is what it sounded like from the claim reps, that the carrier needed more info about the reason(s) for hospitalization. That's not how the letter to the policyholder read, that's what claims said when we called.

 

[somarco]

You need to look at the EOB's, not just take the patient's word for it. EOB's no longer give coding like they used to but there usually is an explanation for why the claim was denied or pended.

 

[yorkriver1]

It was due to "not sufficient reason for hospitalization or ER visit" being given by the ER doc & whoever else made the decisions. So claims says, get the doc or RN on duty to explain reasoning further. Just rejecting the claim out of hand, and then asking for explanation on a sort of appeal seems a bit scorched earth.

 

[leevena]

It was due to "not sufficient reason for hospitalization or ER visit" being given by the ER doc & whoever else made the decisions. So claims says, get the doc or RN on duty to explain reasoning further. Just rejecting the claim out of hand, and then asking for explanation on a sort of appeal seems a bit scorched earth.

While I understand your frustration, this is a normal process. If data submitted (by the hospital or doc ) with the claim does not support the need for the emergency room setting, it will always be turned down. Paying the bill, no matter what, and then determining that it was unnecessary is a wasteful and time consuming process.

 

[yorkriver1]

Claim review is part of managed care, and makes sense. Maybe my lack of deep experience with this particular area of insurance claims makes me react similarly to the claimants. The insured's feel let down and trapped by the situation. They, in good faith, assumed that what the doctors were telling them was a valid need, and now fear having 5 figure debt, due to a seemingly blind siding move by their carrier. I get it.
My goal is to do the best I can to assist in getting legitimate claims paid. I have little idea how to proceed if they are turned down.
The way the letter is worded and the situation handled blew both of them away, now scared and angry. So far, the admin at the employer has not heard much, but they will in time. I called early this week to reassure them I was looking into both situations. The admin in charge of group insurance had not known of it, but on the way to employer holiday party, may have heard later. Glad of my timing.