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I'll try to sum it up: Wife went in for an emergency room visit to due severe abdominal pain. Ended being a 2 week ICU stay, several surgical procedures during that time, and 1 week in a normal recovery room, for a total of 3 weeks in the hospital. Her bowel had ruptured and she was septic. They had a hell of a time getting the infection under control, and she had several abscesses in her abdomen. Thus the long stay.
So now she's been out for a week. I get the bill from the hospital, and have to pay up to my max out of pocket. They give me a 25% discount for doing so. But here's the bad part. I get home today and there's a letter from my insurance saying they've determined the last week of my wife's stay wasn't medically necessary. It doesn't elaborate further than that. So of course I have to appeal this. I'm expecting a long, drawn out process, but don't know what to do from here.
I see a copy was sent to the hospital also. So do I call them and see if they can file the appeal? Or do I have to do so myself? I imagine I will need to submit more than just a letter stating I disagree and will need some sort of documentation. What a pain. All told, I'm out $7500 out of my pocket, after insurance, and now who knows how high it could go if they don't reverse that decision. Also will be without her income for a few months (no std at her job, so waiting for ltd to kick in) and this could ruin us. Plus she isn't finished, she needs 2 more surgeries with hospital stays in the next year and half to finish correcting her issues.
First of all, it's disgusting that we are dependent on our health insurance. The ER is not some place I even like to take my daughter due to her fathers insurance. They are not in network; so it's an 80/20 split after an $800 deductible
What I've learned is to make sure everything is billed correctly. When you get the actual insurance EOB (explanation of benefits) you will see what's paid & what's not. It will also show if there are any "discounts"
Don't get worked up over the bill yet. My hub has cancer, he's 6 months out of treatment & the bills still are not right. I'm on the phone regularly with companies/insurance
I would copy any and all correspondence to the state insurance commissioner from this point forward and if possible I would pay an attorney to "write" a letter of inquiry on the reasons for denial. Once the company determines a policy holder won't lie down and die, and will raise costs and possibly impediments to their sleazy tactics, payments can get expedited.
I am suprised that the doctor did not already contact the insurance on the longer stay when it became necessary. Your going to need to get the doctor to do this as its a medcial determination. Noramlly a patient is first given a code for treatemnt that include a number of days needed. When it appear more are need the dcotor has the stay extended by contracting the insurance for a medcially necessary exention. I have had this done.It really sounds like the doctor screwedup i not gettting the saty extended past the noraml amount allowed under the treatment code.
I'll try to sum it up: Wife went in for an emergency room visit to due severe abdominal pain. Ended being a 2 week ICU stay, several surgical procedures during that time, and 1 week in a normal recovery room, for a total of 3 weeks in the hospital. Her bowel had ruptured and she was septic. They had a hell of a time getting the infection under control, and she had several abscesses in her abdomen. Thus the long stay.
So now she's been out for a week. I get the bill from the hospital, and have to pay up to my max out of pocket. They give me a 25% discount for doing so. But here's the bad part. I get home today and there's a letter from my insurance saying they've determined the last week of my wife's stay wasn't medically necessary. It doesn't elaborate further than that. So of course I have to appeal this. I'm expecting a long, drawn out process, but don't know what to do from here.
I see a copy was sent to the hospital also. So do I call them and see if they can file the appeal? Or do I have to do so myself? I imagine I will need to submit more than just a letter stating I disagree and will need some sort of documentation. What a pain. All told, I'm out $7500 out of my pocket, after insurance, and now who knows how high it could go if they don't reverse that decision. Also will be without her income for a few months (no std at her job, so waiting for ltd to kick in) and this could ruin us. Plus she isn't finished, she needs 2 more surgeries with hospital stays in the next year and half to finish correcting her issues.
I am so sorry to hear about your wife's ordeal, and I hope all goes well with her planned treatment.
It is so obvious that this is a medically necessary admission, that I have to believe it will easily be resolved. The hospital billing office and her physicians should be very happy to help you out, as should human resources at the employer through whom you have the insurance. Take a deep breath and relax. You are not going to have to declare bankruptcy!
Chickpea is correct about using your state insurance commissioner, but there are some things you need to do first. It is a bit early to bring in the lawyers.
First, get a copy of the entire bill --- not just the summary. Look over it yourself first to see if there are any glaring errors. You are looking for things she was billed for that you know she did not use. Then, ask her doctors to do the same thing. Most bills for stays that long are going to contain errors. This is just due to the fact that it will involve entering lots of codes into a computer, and it is very easy to enter the wrong code accidentally. Newer computerized systems reduce errors, but do not eliminate them. Anyone who has a hospitalization should do this step.
Keep records of everything. When you talk to someone, get his or her entire name, record the date and time, and write a note summarizing what was said. Save any emails.
Now, call the office of the primary doctor who managed her care. That is probably the surgeon. S/he should write a letter to the insurance company detailing the reason for the last week in the hospital. The hospital billing office may have already asked him to do this. Ask for a copy of the letter to go in your file and ask for a copy to be sent to human resources at the employer. You want them to know the insurer is giving you a hard time. This will influence the employer's choice of carrier in the future. If the employer is big enough, the insurance company may see potential loss of the entire contract as a serious threat.
These days there are people who work in hospitals who do nothing but review the status of inpatients on a day to day basis to determine whether another day in the hospital is indicated. If they have a concern, they let the attending doctor know. It is very likely that those last seven days meet standard criteria for continued admission. The letter from the doctor will contain that info, and that should resolve the problem.
Now the good news. If it is determined that those seven days were not appropriate --- if your wife could have been cared for in a less expensive setting -- say at home with home health care, you may not be responsible for the charges. Why should you pay if it was truly not medically indicated? The hospital should write it off. Do not pay anything until you have reached some sort of final resolution of the situation.
If the letter detailing the reason for the last seven days does not resolve the problem, your wife's doctor needs to speak to the insurance company's doctor. The original denial very likely came from someone with a high school education who was going by a checklist. S/he may have no medical training at all. The insurance company doctor will not speak directly to you (or your wife.) When your wife's doctor speaks to the insurance company doctor, again I would expect a favorable resolution of the problem.
Doctors and hospitals deal with appeals issues all the time. They know how the system works.
Only if none of the above helps make the problem go away do you go to the state insurance commissioner. However, ask your wife's doctor --- or more than one --- to write the letters. You may even provide a copy of your file --- remember those dates and times and names --- to include. It is unlikely that the insurance company will want it to go that far, as they are now exposed to possible fines and even the loss of the ability to sell in your state if there are enough complaints. There are also penalties for delaying payment of claims, and the company can be made to pay interest if the payment is found to be intentionally tardy. If there is a pattern of trying not to pay large bills -- and I expect your wife's is a hefty one --- the commissioner will not like that either.
Don't panic! Concentrate on helping your wife get better. And, did you thank her doctors and the hospital staff? You probably did so verbally, but did you send a note or a card? You can't imagine how uncommon and how appreciated those are.
Thanks for the tips and advice. We are both completely stressed out about this. I'm expecting it to be such a hassle to get all documentation from the providers. But meanwhile I'm responsible for whatever the insurance denies, on top of the outrageous out of pocket. As of yet I don't know the amount. It's hard having to wait til Monday to start chasing down answers. Insurance is such a joke.
Thanks for the tips and advice. We are both completely stressed out about this. I'm expecting it to be such a hassle to get all documentation from the providers. But meanwhile I'm responsible for whatever the insurance denies, on top of the outrageous out of pocket. As of yet I don't know the amount. It's hard having to wait til Monday to start chasing down answers. Insurance is such a joke.
The best you can do is 1) make sure the insurance information is correct; even if you have to drive to the hospital & visit billing.
2) call insurance & ask how to appeal & start appealing.
I may have a copy of my appeal letter if you need help.
From what I remembered, I stated the facts - child injured, had to rush to nearest hospital.
With you, you state the facts - also including why she needed to stay.
Looking at mine; I spoke to an insurance rep; who after hearing the events of that day, put the claim back through. This happened one or two more times, then I filed the appeal.
Appeal letter - things to include
Claim #
I.D. #
Patient name D.O.B.
Date of service
To Whom It May Concern:
Patient went to ______ hospital's emergency room due to severe abdominal pain. You can say what was done.... Her bowel had ruptured and she was septic; which they had a rough time getting the infection under control. She also had several abscesses in her abdomen.
She had a 2 week ICU stay, during that time several surgical procedures during that time, list each..
She was then moved to a normal recovery room, add what's needed here..
My wife was in the hospital for a total of 3 weeks. Whatever info you can add here...
A few weeks have gone by since her emergency stay at such & such hospital. I am now getting bills from (list who & amount) I called both places and was told the claim was denied. I then called insurance company name, speaking to name of rep. who informed me that yes, the claim was denied. It was suggested that i file an appeal, hence my letter today.
I hope this letter clears up the events of that day, so that you can see it really was an emergency and I had no choice but to take my wife to ____ Medical Center that day. I was told by someone at insurance name that it would be covered. All of the charges from that day were the result of being seen at ____ Medical Center through the Emergency Room. I don’t understand why the ER visit was covered but her hospital stay was not (or something to that effect).
Looking at mine; I spoke to an insurance rep; who after hearing the events of that day, put the claim back through. This happened one or two more times, then I filed the appeal.
Appeal letter - things to include
Claim #
I.D. #
Patient name D.O.B.
Date of service
To Whom It May Concern:
Patient went to ______ hospital's emergency room due to severe abdominal pain. You can say what was done.... Her bowel had ruptured and she was septic; which they had a rough time getting the infection under control. She also had several abscesses in her abdomen.
She had a 2 week ICU stay, during that time several surgical procedures during that time, list each..
She was then moved to a normal recovery room, add what's needed here..
My wife was in the hospital for a total of 3 weeks. Whatever info you can add here...
A few weeks have gone by since her emergency stay at such & such hospital. I am now getting bills from (list who & amount) I called both places and was told the claim was denied. I then called insurance company name, speaking to name of rep. who informed me that yes, the claim was denied. It was suggested that i file an appeal, hence my letter today.
I hope this letter clears up the events of that day, so that you can see it really was an emergency and I had no choice but to take my wife to ____ Medical Center that day. I was told by someone at insurance name that it would be covered. All of the charges from that day were the result of being seen at ____ Medical Center through the Emergency Room. I don’t understand why the ER visit was covered but her hospital stay was not (or something to that effect).
Sincerely,
Name
Address
Phone
CC -
As I understand it, only the last seven days were denied, not the whole admission. The letter will need to come from OP's wife's doctor and document the need for the last seven days, not the whole hospital stay. This is in essence the time she spent in the hospital after she was discharged from the ICU. The insurance company is likely to allege that whatever services were supplied during that time frame could have been given in a less expensive venue, such as a rehab center or at her own house with home health nurses. This would be things like physical therapy to help her get her strength back, care of an incision that might be healing slowly due to the infection she had, completion of the antibiotics for the infection, or training in ostomy care.
If the appeal goes through the physician's office, it is likely to move faster. The treating doc will need to explain for each of those seven days at least one thing that was going on that could not have been treated anywhere except the hospital. OP's wife's doc may need to talk to the doc who represents the insurance company. The insurance company doc will not speak directly to a patient --- been there, tried that. And OP is not going to be able to explain the medical reasons for the last seven days stay.
11thHour ~ The likelihood that this will be resolved in your favor is very high. Enlist the aid of your wife's physicians. Again, you are not likely to have to pay for any days that are determined to be "medically unnecessary", unless you were told in advance that the insurance would not cover those days. Many years ago, patients were not sent home until they were pretty much well. Now there is a lot that can be done as an outpatient, and the insurance company is banking on being able to say that is true in your wife's case. My son is a social worker for a hospital in a small city. Part of his job is to review what is going on with patients and make sure they are discharged as soon as they are medically ready, not one day later. If it looks as if the patient is being held over too long, the doc is alerted to document in the chart the need for continued hospitalization. You cannot stay in the hospital and "rest and recuperate" anymore!
He needs to make phone calls 1st. I posted the mock up letter because my windows computer just happened to be running; just in case he needs it.
Most hospitals won't give a crap. Depending on what doctor/hospital, the doctor may not have an office outside of the hospital & only see patients on the floor. My hub was in a trauma center where they did this.
The hospital should have called the insurance to get the authorization to keep her.
I might even put an order in for her records while admitted - the whole stay - including ER because it will show history.
Usually you don't have to file the appeal; the phone calls to the billing office, then the insurance company & maybe a time or 2 more; this all should be taken care of. Depending on the outcome of the phone calls to the hospital, I might go there in person to speak to a supervisor. If not, I would start getting everything ready to appeal.
What type of insurance do you have?
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