Insurance Questions Emergency

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arco
arco Member Posts: 13
edited June 2014 in Employment, Insurance, and Other Financial Issues

Any advice?

My wife ran a fever for a few days that snuck up near 102, so her oncologist had her go to the ER. It did turn out, after 3 days in hospital, her mediport was infected, but not internally..on the surface.  However, our insurance is questioning the ER visit and not paying the doctor's fee because it was a NON_EMERGENT ER visit.

 I'm filing a grievance, but i'm wondering if anyone out there has dealt with this - tips on how to approach the insurance company, what to include in my grievance letter?

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  • naty41
    naty41 Member Posts: 28
    edited May 2011

    Can you get the ER or Oncologist to help you. I had a problem with Medicare about 4 years ago when they refused to pay the bill - I disputed it but they only paid about 10 percent of the bill and the bill went to collections. I refused to pay the difference so my credit is bad now! Maybe you can hire an Attorney. Sorry can't be of much help on this issue!

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  • otter
    otter Member Posts: 6,099
    edited May 2011

    "My wife ran a fever for a few days that snuck up near 102, so her oncologist had her go to the ER."

    Ordinarily, a temp "near 102" might not be considered an emergency warranting a trip to the ER.  But, for someone with a port, who was told to go to the ER by her oncologist, it sounds like a slam-dunk.  Sometimes these things are given a knee-jerk response by insurance companies, and they just need to be slapped a couple of times to wake them up.

    It's been my experience that the first place to go for help is the doctor who wrote the orders.  Doctors like to get paid, so their offices are usually willing to file the first appeals.  Sometimes it doesn't even take an "appeal" -- all it takes is somebody to de-code the insurance company's objections, and re-file the claim with the correct numbers in the proper blanks.

    OTOH, ... about 25 years ago, I had "lithotripsy" for a kidney stone, and my insurance company denied the claim because lithotripsy was "experimental".  Well, it turned out that the FDA had approved it for exactly my situation just a few weeks before my procedure.  I wrote a letter to my insurance company, reminding them of the FDA ruling ... and they wrote back with an apology and a full payment.  Stupid is as stupid does. (~ Forrest Gump)

    otter

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  • Thriver
    Thriver Member Posts: 10
    edited May 2011

    Hi,

    What kind of insurance do you have - a work HMO, PPO, or Medicare/Medicaid?  I am a long term cancer survivor and have been working as an insurance appeals advocate for 11 years.  I have done many appeals and would be glad to help.  However, I need more info.  The rules vary somewhat depending on what type of insurance you have.  What state are you in?

    Thriver

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