Hello,

I am 24 years old and mostly on my own. I will come right out and say that I am very ignorant when it comes to insurance and the details of how it works or should work. I just pay my bill every month and hope that I don’t need it! I have been, for the most part, a pretty healthy person.

I live in Sacramento, CA and have Blue Cross Select HMO coverage. My primary medical group is Mercy Medical Group (formerly MedClinic)


Well, last month, I had a severe episode of PSVT and was ambulanced after calling 911 to the nearest hospital. My condition was very severe and they needed to get me to an ER ASAP. I arrived at Sutter General hospital, which is not covered by my insurance. That was honestly the last thing on my mind and didn’t even occur to me.. My girlfriend followed behind and met me at the ER and provided them with ALL of my insurance info.

I was treated in the ER all day and was admitted later that evening to the ICU. My parents, who luckily are very knowledgeable about insurance stuff were smart enough to contact my primary care physician to inform him of what had happened and were I was located, since I was at a non-covered hospital.

After being in the ICU for 2 days, it was decided by an electrophysiologist at the hospital that I needed an RF ablation (heart surgery) to correct my problem and that it I would be transferred to Sutter Memorial hospital for the procedure.

I was released 1 day after the surgery, so I was in the hospital for a total of 4 days. 2 days at Sutter General, and 2 days at Sutter Memorial. Again, both are not part of my medical group.

So about 2 weeks ago, I got a bill from Sutter General for my ER stuff. It was about $900. I was confused by this and called them on it. Apparently, for some reason, my insurance was not attached in their computers to my account with them. So I guess that got figured out ok.

Then a week later, I got an “Explanation of Benefits” from Blue Cross stating that it was my responsibility to pay $116,600.00 (no, that’s not a typo)

The letter said
This service is not payable because it was not authorized by the member’s Participating Medical Group (PMG).

Then I got another letter from Blue Cross basically stating the same thing.. that.. “Your Participating Medical Group has informed us that these services were not authorized by them.
And
We regret therefore, that no payment can be made for these services.

I knew that this issue could possibly come up, but I (and my parents) figured that it was not an issue because we felt that everything WAS authorized. They spoke with my doctor and my doctor was informed (supposedly) every step of the way while I was hospitalized. I also figured that the hospital staff would be kind enough to be sure that my care was authorized by my PMG, and not just randomly operate on me without talking to my doctors first.

I gave my doctor a photo copy of all of these documents but have yet to hear back from him.

Does anyone have any advice? Am I really responsible for this bill?!?! What am I supposed to do if it doesn’t work out in my favor?!

I’m sorry, I’m just really freaked out… this could ruin me. :mad:

Thanks for your help. :)

I'm not familiar with HMO's, I'm on a PPO. However, I had insurance issues when my son was born. It's a very long story but similar to yours in that everyone from the nurses and doctors to us communicating with the "insurance company" daily (some days we contacted them mulitiple times). We made sure that we covered all our bases. Anyway, I want to advise you to keep pushing. Make note of dates, names and keep accurate records (paperwork, phone conversations, etc.). If push comes to shove, you might need to seek legal advice. We hired an attorney on a contingency basis (if he didn't win, we didn't owe him anything). We ended up settling out of court. Insurance companies don't want their names attached to messy lawsuits.

Keep up the pursuit. It might be very long and drawn out (it took us more than 2 years) but it WILL be worth it. Hang in there and GOOD LUCK!!!

Julie

P.S. My attorney told us that some (very few) insurance companies automatically decline payment on a certain percentage of high dollar claims. They're banking on the consumer not fighting back. Then, they're not out all that money. Makes sense, huh? Not saying your insurance company would do that, but we believe that's what happened in our case. It was a messy battle....

thanks for the advice. im sure it will work out eventually.

i hope... : /

Wow, ouch.. I hope this all gets sorted out. My experience with HMOs is that in event of a true medical emergency, you should be covered as in-network if you are taken to the closest medical facility which is not a part of your network. But then you are to be transported to an in-network facility for further treatment once you have been stabilized. So it would seem to me that in your case, if the surgery that you had was urgent and had to be performed immediately, that claim should be covered by your HMO. And in which case of course there was no time for pre-authorization. If this was your situation, the doctors who provided your care should be able to provide documentation and hopefully assist you in fighting the bill. It also works to your favor that your parents contacted your PCP as soon as possible. Your PCP should have provided some instruction as to how to proceed with your care. If it was a situation where you could have been stabilized and then taken to your in-network hospital to complete the procedure without endangering your health, then it is routine that the HMO would deny the claim and there might not be much basis for fighting them. But the fact that you were in the ICU seems to indicate otherwise. Sorry for all you've been through, and then to have to deal with all of this on top of it. Best of luck to you in straightening it out!

thanks very much for that extra insight. you pretty much have it exactly right.

fortunatly, i was able to contact my pcp and he forwarded the situation to my network's billing dept. an agent there found the anthorizations and has forwarded them to blue cross. so i would assume that it will get sorted out at this point, however, im sure it will take quite some time!


thanks agian,

keith