Question
Mississippi
My insurance, (which is usually excellent) covers ER treatment at non-PPOs and PPOs the same way (100% after deductible).
After an emergency appendectomy, classified at the ER as level 4, my treatment was classified as non-PPO inpatient rather than as an emergency. The difference in my pocket being about 2000.00 for the second classification.
I filed an appeal. It was denied. Many questions later with my company's Benefits department and with Principal (3 different people-the supervisor is on a weeks vacation) I am still unable to get an answer to the question,
"In an emergency where you are admitted for emergency treatment, will the classification be emergency or inpatient?"
I have been told, "It depends on the wording of the policy." "It is judged on a case-by-case basis", "We have had some recent changes to our policy. They were posted on our intranet site."
I am filing a second appeal. I am also considering hiring a lawyer. The cadginess of the people I've talked to makes me suspect that I have a case that I may win. What do you think?
Answer
It is entirely dependent upon what your insurance policy says.
Answer
It does indeed depend entirely upon the wording of your insurance policy.
While understanding that you had a medical emergency and HAD to have immediate surgery, the problem is that this was not a PPO hospital. That being the case, your insurance company did not receive the discount on the services provided that they would have had it been a PPO hospital and thus, there were no savings to pass on to you. That's the whole basis of PPO provider vs. non-PPO provider. The PPO providers have agreed to provide discounts to your insurance carrier/employer and therefore it costs you less because of the savings involved.
Answer
You are right, I am going to get the complete policy, all i have it the summary.
But, according to the summary, ER visits at a non-PPO are 100% after a 600 deductible plus any charges above customary and ER visits at a PPO are 100% after a 300.00 deductible. My gripe is that my ER treatment became non-PPO at only 60% coverage after I was admitted for sugery and had to stay for two days. So now none of it is being treated as ER.
Is that normal?
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I am guessing, but I think what may be at issue here is how soon your condition was considered "stabilized". Most policies will allow ER charges at network rates, but the policy will then call for transfer once stabilized. Look into this, because being an appendectomy as you described, the ER would definitely classify as emergent. If the additional charges are stemming from the additional time you spent in that facility, please do point out to your insurer that the cost of transfering you to a network facility was likely higher than the cost of your remaining where you were. Also ask if they have a Utilization Review department that was following your case. If so the UR dept should have instructed the provider as to the proper procedure. I think you can win this one, but do your homework. Impassioned pleas don't usually work. lkc15507
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I was starting to think I had missed a logical thought progression in this case that no one else was having any trouble with. That makes it hard to know what to do next. Now I have something I can do! I will definately follow your advice. Thanks again!
Answer
Also, most PPO's will pay up to 100% of reasonable and customary charges for non-PPO facilities, which is not necessarily 100% of the charge the facility is making.