On Oct 15th, I called 911, who sent an ambulance and took me to the emergency room in the nearest hospital. A few hours later, I was transferred to another hospital in midnight because the first hospital was not able to handle preterm labor. A few days later, the first ambulance company sent me a bill of $2,545, and the second one sent me a bill of $7,859. The first ambulance company got my insurance information and filed the claim directly. The second one did not have my insurance info, and therefore they offered me a special uninsured discount: I only had to pay $1,200.
So my insurance company, Anthem Blue Cross processed the first bill, and sent me an EOB, saying I had to pay approximately $2,300 because that company is "out-of-network". After they received the second bill, they agreed to pay $4,600 for the same reason. As a result, I was responsible for about $5,500 for the two ambulance rides, which is even higher than the price for "uninsured" people.
This is not the end of story. It turned out that during my emergency surgery, the anesthesiologist and the surgeon, who work in the “in-network" hospital, are not "in-network" physicians. As a result, their bills were also taken as "out-of-network" as well, which added a few more thousands dollars.
Is that bad enough? No, far from the end. When you physicians insist you staying the hospital for six days, your insurance company may find only four days are "medically necessary". I stayed in ICU for four days, and then a private room for another two days. I kept receiving mails from my insurance company saying we only found the first four days are medically necessary, therefore oops we could not cover your hospitalization stays for the last two days. Well, then how about covering the first four days? We can't do that either because we only cover semi-private room while you were in a private room.
Under emergency, there are a lot of things out of control: I couldn't ask 911 to send me an "in-network" ambulance; I couldn't ask the hospital to transport me in an "in-network" ambulance when I was unconscious; I couldn't choose my surgeons and anesthesiologist after I lost 2-liter blood and fell into coma; neither could I choose a semi-private room in the hospital since I woke up two days after the surgery. However I had to deal with the extra bills which added up to more than $10,000.
When you feel you're treated unfairly, usually you are not alone. People with similar experience can provide you with good suggestions on addressing issues like this. What you need to do is to Google your concerns. And that's what I did as the first step. After studying cases online for a few hours, I established my argument and started to look for evidence.
Therefore I read the part on insurance coverage in the Affordable Care Act (ACA) and state legislation, which makes it very clear that in emergency, the insurance should cover "out-of-network" bills at the same rate as "in-network" ones; and balance bills are forbidden for both PPO and HMO policy holders. In other words, it's an obvious violation of law for my insurance company to process my bills as non-emergent "out-of-network" ones, and I should not be balance billed at all!
Then I appealed all the claims that I was not happy with. Without any new evidence (such as medical records or visit notes), all my appeals got re-processed and in-network rates were applied. In other words, with exactly the same information, my insurance company processed these claims in two very different ways. There are two possible explanations for this: (1) the company hires some unqualified people who simply do not know how to process claims without violating laws; or (2) the company is taking advantage of me, in hope that I am not familiar with the federal/state laws so that they can pay less.
We shouldn't have to be experts on health insurance to be treated fairly. Unfortunately ethical standards for some companies can be really low. Even I know they are in violation of law, what can I do? I can only appeal the bills, but I can not sue them. So for the company, the cost is very low but the gain is big: if the patient finds out that his claim is not correctly processed and makes an appeal, it probably only takes them a few minutes to re-process the claim; but if the patient does not realize he is over billed, or he does not know that he can make an appeal, then the company can pay much less than it should. This is a game that the company will never lose.
Now I finally understand why my physician gives me an eight-week disability leave - it's not for me to have a good rest, but to deal with these shits. It's unpleasant to spend hours talking to insurance representatives and teaching them the right way to process a claim, and it's also interesting to see the exorbitant medical prices. Just think about the bill from the second ambulance company: it was willing to accept a payment of $1,200 for the ambulance, but my insurance ended up paying the full price of $7,859. Its employees must have a good bonus for Thanksgiving this year.
There are a few more claims in process, and I won't be surprised if some horrifying bills come again. I only hope that I can get everything done before I'm back to work. After witnessing all the messy stuff in the US healthcare, I strongly believe that I've made a good choice in my career life, I'm in the right field.
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