Wiki Doctor seen in ER not being covered

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MagenD

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Joliet, IL
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I have a family member who recently suffered a heart attack. She was brought in by ambulance to the nearest hospital which was out of her network. After being admitted in the hospital for 3 weeks following extensive surgery, the hospital stay itself was covered by her insurance. However, the provider she was seen by is not being covered at all due to being out of network. I just want to make sure I help her get this taken care of properly. In this case, I'm thinking the provider would need to do a prior authorization or possibly submit documention to support why she was seen. Any suggestions?
 
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She (if able) (or you or her representative with her permission) can call the insurance company and indicate this was an emergent situation and she did not have the ability/choice to pick an in-network facility. Ask them to cover the pro-fee of the ED doctor as in network. Point out that the hospital stay was covered. It's the same kind of thing that happens when someone chooses an in network doctor and facility for an elective surgery but the anesthesia provider is out of network.


What are the new protections if I have health insurance?
If you get health coverage through your employer, the Health Insurance Marketplace®, or an individual health insurance plan you purchase directly from an insurance company, these new rules will:
  • Ban surprise bills for emergency services, even if you get them out-of-network and without approval beforehand (prior authorization).
 
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amyjph said:
She (if able) (or you or her representative with her permission) can call the insurance company and indicate this was an emergent situation and she did not have the ability/choice to pick an in-network facility. Ask them to cover the pro-fee of the ED doctor as in network. Point out that the hospital stay was covered. It's the same kind of thing that happens when someone chooses an in network doctor and facility for an elective surgery but the anesthesia provider is out of network.


What are the new protections if I have health insurance?
If you get health coverage through your employer, the Health Insurance Marketplace®, or an individual health insurance plan you purchase directly from an insurance company, these new rules will:
  • Ban surprise bills for emergency services, even if you get them out-of-network and without approval beforehand (prior authorization)
Click to expand...
The insurance likely has all of the providers loaded in their claims processing system as OON, they went through auto adjudication and denied or paid OON rates. The hospital bill was paid INN without you calling because it probably had to be reviewed by a person because it was a large dollar claim. It really may be just a simple call to her asking to have any of the OON providers (Like ER doc-Path/lab-Anesthesia, Surgeon, Assistant surgeon etc) claims reprocessed under the NSA that went into effect 1/1/22 .. She should only be responsible for her INN cost share amounts (if any). If she wasn't stable enough to transfer to an INN facility, she really had NO choice in any of it.
 
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