BCBS Paid Only Part of Emergency Room Visit

[jerrystorey]

I have BCBS of NC. I had a accident with my hand. My policy allows me to pay $150.00 Deductable with an emergency room visit and BCBS will pay the rest.
My problem is that a surgeon had to be called in to do emergency surgery and was not affiliated with the hospital. When he billed BCBS, he had to bill it as outpatient because he was not affiliated with the hospital. Therefore BCBS will not cover it under a emergency room visit.
Something is wrong with the system. Can someone help me out?
Thanks - Jerry

 

[Crabcake Johnny]

Medical emergencies are billed as in network - start fighting.

 

[TXINSURANCE]

Medical emergencies are billed as in network - start fighting.

This is not a hard rule. If the surgeon did not have a contract with BCBS then BCBS is not under obligation to discount anything.

I bet the $150 (which is absurd btw - way to low) is not a deductible (note spelling) - I bet it is a CO PAY and you are on a HMO plan.

That is my guess. And yes good luck fighting!!!

 

[Crabcake Johnny]

Would have to look at the policy - BX in MD; all medical emergencies are billed at in-network rates, regardless.

The issue? The carrier, not doctor or hospital gets to deem what's an emergency and what's not.

However, they can appeal to the MD DOI and they do a decent job of reversing this junk.

 

[TXINSURANCE]

Read his first line - ...

My policy allows me to pay $150.00 Deductable with an emergency room visit and BCBS will pay the rest.


That's not a deductible, thats a co pay. I guess it could be PPO or HMO, who knows... So many variables who knows where to begin, I predict it will get resolved in under 12 months :-)

 

[Crabcake Johnny]

I've fought stuff like this and won in a relatively shot period of time. Won two OON anesthesiologist claims recently. Both scheduled procedures, both in-network facilities, etc...

 

[TXINSURANCE]

Me too...

I had an ambulance come to my dentist off to take me to the ER, after my dentist made a sever unproven error. This is 100% legal in Texas, as you have no right to any dental investigative reports by law - so in Texas your dentist can attempt to kill you, no problem - you will never know what happened. Dentists are protected by laws you couldn't even imagine.

Anyhow...

The ambulance that came was out of network - imagine that!!! Since virtually none are contracted. The stupid insurance company told me I could have called an in network ambulance (over an hour away)? They are nuts, 911 was called.

I finally won, but it took about 6 months of non stop stupidity. It is issues like this that lead to talk of Federal insurance take over. There is no excuse for this.

 

[Crabcake Johnny]

"Network ambulance?" Lol. Over here they're all private.

 

[dgoldenz]

Maybe I'm reading things wrong, but I think the OP was billed for outpatient services, not as out-of-network. The outpatient services are probably subject to deductible aside from the ER co-pay.

 

[somarco]

The surgeon is non-par. Not surprising for ER claims. He can bill what he wants in xs of the negotiated rate BX will use in adjudicating the claim.

You can fight but it won't do any good. Surgeon can and will balance bill and you have to pay.

BCBSGA used to have a similar ER benefit and some other carriers copied it. Aetna & Coventry for example have $250 - $500 deductible (really a copay) and carrier pays xs at 100% of negotiated rate.

These are PPO/POS plans, not HMO.

The claimant can certainly appeal the OON penalties (if applied) but has absolutely no leverage with the non-par doc.