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  • Health Insurance: Emergency in Network?

    Hello,
    I work 80 miles from where I live and have nothing as a tier 1 insurance network. I work for the largest hospital provider in Indiana so they only have themselves as tier one but there are none of them in northern Indiana. I do have a tier 2 close by.

    my wife is pregnant and I have an HSA plan. OOP individual/family is 6000/12000 respectively for tier 2 and 3750/7500 for tier 1.

    my insurance told me previously any emergency is consider tier 1, they made it seem like this is the law. Does anyone know this? I have used this to my benefit twice already and had hospital stays for my little one and an urgent care visit covered as tier 1. I call pcp, document they told me to go to ER, record symptoms and vitals, blah blah blah.

    my question is, can I just say the hospitalization for my wife’s delivery is an emergency as well and have that covered as a tier 1. It would effectively save me 4500$ and I would be more likely to just pay the bills and keep my HSA funded.

    I think if it is actually federal law that emergencies are covered by insurance, I might have an argument.

    i know this is a little different of a topic but may save us with HSA some cash and help others besides me.
    Last edited by Ekanive23; 04-14-2022, 06:16 PM.

  • #2
    I can't speak for your particular insurance but there's no such law to have your 'emergency' covered under insurance. There are plenty of out of network insurances with emergency providers. If you're speaking about the emergency physicians themselves then it would be a good idea to find out what group staffs the ED and find out if they're covered by your insurance because chances are that the hospital doesn't employ these physicians so you can have an in network hospital and out of network providers. It isn't uncommon for this to happen with the ED, Radiology, Pathology, Anesthesia, etc.

    Comment


    • #3
      There are millions of births/year. Only a small fraction could be considered an emergency delivery.

      While I am not a medical professional, I seriously doubt you can just claim it is an emergency. The hospital and the insurance company most likely have specific criteria/codes and who is authorized to make that determination.

      Comment


      • #4
        Originally posted by CordMcNally View Post
        I can't speak for your particular insurance but there's no such law to have your 'emergency' covered under insurance. There are plenty of out of network insurances with emergency providers. If you're speaking about the emergency physicians themselves then it would be a good idea to find out what group staffs the ED and find out if they're covered by your insurance because chances are that the hospital doesn't employ these physicians so you can have an in network hospital and out of network providers. It isn't uncommon for this to happen with the ED, Radiology, Pathology, Anesthesia, etc.
        Isn’t the No Surprises Act supposed to make this a thing of the past?

        Comment


        • #5
          You really need to look at your state insurance and the federal insurance links.
          https://www.in.gov/healthcarereform/no-surprises-act/
          Most employers plans are actually self insured. There is some requirements to actually provide access to in network, typically within 50 miles.
          Better choice would be to press your insurance for in network coverage for your situation. Exceptions are made and you don’t live in a constant state of emergency coverage.

          Comment


          • #6
            From healthcare.gov: "Insurance plans can’t require higher copayments or coinsurance if you get emergency care from a hospital outside your plan's network. They also can’t require you to get prior approval before getting emergency room services from an out-of-network provider or hospital"

            I would say if you called your OB and they advised going to the ER and first arrival documentation was with ER I would think you would have fair argument. Not sure the hassle is worth worrying about. If it were me I would just let things play out and if it looked like I could prove it was emergency on the back end after all was said and done maybe I would try.

            Comment


            • #7
              Originally posted by pierre View Post

              Isn’t the No Surprises Act supposed to make this a thing of the past?
              You’re absolutely correct, my mistake. We try to make it a point to come to an agreement to be in network with all insurances the hospitals we’re at are in network with so I think the above situation is pretty rare for us.

              Comment


              • #8
                Originally posted by Otolith View Post
                From healthcare.gov: "Insurance plans can’t require higher copayments or coinsurance if you get emergency care from a hospital outside your plan's network. They also can’t require you to get prior approval before getting emergency room services from an out-of-network provider or hospital"

                I would say if you called your OB and they advised going to the ER and first arrival documentation was with ER I would think you would have fair argument. Not sure the hassle is worth worrying about. If it were me I would just let things play out and if it looked like I could prove it was emergency on the back end after all was said and done maybe I would try.
                Here’s where it’s going to get sticky because at many places those over 20 weeks and with primarily pregnancy related complaints get taken to L&D and aren’t actually seen in the ED. I honestly don’t see how one would argue a hospitalization for a pregnant person is an emergency if she’s term, etc. It’s going to be a mess because everyone (especially after hours) tells patients to go to the ED all the time.

                Comment


                • #9
                  Originally posted by Otolith View Post
                  From healthcare.gov: "Insurance plans can’t require higher copayments or coinsurance if you get emergency care from a hospital outside your plan's network. They also can’t require you to get prior approval before getting emergency room services from an out-of-network provider or hospital"

                  I would say if you called your OB and they advised going to the ER and first arrival documentation was with ER I would think you would have fair argument. Not sure the hassle is worth worrying about. If it were me I would just let things play out and if it looked like I could prove it was emergency on the back end after all was said and done maybe I would try.
                  that was my impression. My next one, does emergency care stop at the emergency room or would it be that admission stabilizing the patient.

                  Thanks,
                  eddie

                  Comment


                  • #10
                    From the website. An example.

                    Hannah calls the insurance company to ask for a list of in-network pediatricians, the insurance company has one business day to give her a list. If Hannah relies on inaccurate information from the insurance company that a provider is in-network, then Hannah will be responsible only for the in-network deductible, copayment, or coinsurance.

                    this exact example was me and forced my hospital system to pay 500,000 in bills since they are self insured.

                    Comment


                    • #11
                      Originally posted by Ekanive23 View Post
                      From the website. An example.

                      Hannah calls the insurance company to ask for a list of in-network pediatricians, the insurance company has one business day to give her a list. If Hannah relies on inaccurate information from the insurance company that a provider is in-network, then Hannah will be responsible only for the in-network deductible, copayment, or coinsurance.

                      this exact example was me and forced my hospital system to pay 500,000 in bills since they are self insured.
                      Wow crazy. Not surprised the list was wrong

                      Comment


                      • #12
                        Originally posted by CordMcNally View Post

                        You’re absolutely correct, my mistake. We try to make it a point to come to an agreement to be in network with all insurances the hospitals we’re at are in network with so I think the above situation is pretty rare for us.
                        Well if you negotiated decent contracts with those insurers prepare for those to be cancelled. Why would Insurers keep them when they can just send what they think is fair and make you go the IDR route to get more. This is already happening. Expect major downward pressure on ED physician earnings. The no surprises act has f**cked Emergency Medicine. And for IDR your risking $250 a pop, what to ask for $200 more.

                        Comment


                        • #13
                          Originally posted by pit.alumni View Post

                          Well if you negotiated decent contracts with those insurers prepare for those to be cancelled. Why would Insurers keep them when they can just send what they think is fair and make you go the IDR route to get more. This is already happening. Expect major downward pressure on ED physician earnings. The no surprises act has f**cked Emergency Medicine. And for IDR your risking $250 a pop, what to ask for $200 more.
                          Exactly. That was the big issue our billing company had when we had these discussions. There's zero incentive for the insurers to negotiate in good faith when they can just slowly push down the reimbursement rates through this. This was touted as a patient protection act but it was mainly for the insurance lobby. What a boon for the insurance lobby when they can do something like this.

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                          • #14
                            Originally posted by childay View Post

                            Wow crazy. Not surprised the list was wrong
                            on our list it said community hospital system was in network. The community where I live is different…. I verified with someone before going to that community and they said it was in network.

                            They paid out as tier one and covered every cost and balance bill

                            Comment


                            • #15
                              Originally posted by spiritrider View Post
                              There are millions of births/year. Only a small fraction could be considered an emergency delivery.

                              While I am not a medical professional, I seriously doubt you can just claim it is an emergency. The hospital and the insurance company most likely have specific criteria/codes and who is authorized to make that determination.
                              Ask a woman in labor if it is an emergency?

                              Comment

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