Out-of-Network, But Not by Choice—How to Get Your Emergency Claim Paid at the In-Network Rate: Part I

You collapse at work, and a co-worker calls 911. An ambulance is dispatched to take you to the nearest hospital where you are admitted. While hospitalized, you undergo multiple x-rays and procedures, utilizing the services of radiologists, pathologists, and anesthesiologists—physicians that you will likely never see (while awake, at least) and whose names you probably won’t recognize when you receive their bills. You’re finally discharged to home sweet home, which just happens to be in a far-flung rural area where there are no INN (In-Network) specialists who can treat your condition within a 60 mile radius. You’re understandably shaken by this sudden turn of events in your life, but you’re focused on getting well as quickly as possible, so you can return to work. All is progressing nicely, until multiple EOBs (Explanation-of-Benefits) start arriving in your mailbox indicating that you owe thousands of dollars for OON (Out-of-Network) services that your insurance plan either doesn’t cover at all or covers only at a paltry percentage (e.g., 40-50%). Your stress quotient increases exponentially, and you teeter on the edge of sheer panic at the thought of owing so much to OON healthcare providers that you had no part in choosing due to the emergent nature of your illness and/or the special circumstances involving continuity of care. Moreover, the idea of battling your insurance company on the legitimacy of the astronomical charges while convalescing is enough to send you back to the ER.

As someone who’s intimately familiar with the labyrinthine bureaucracy of health insurance companies, I understand the unfairness of erroneous OON charges to plan members’ bottom lines. I offer the following tips to getting your OON charges justifiably reprocessed at the INN rate:

*Contact your insurance company ASAP about OON charges incurred due to emergency situations. In some cases, claims representatives can simply send your claims for reprocessing with the information you’ve given them. However, in most cases, you will have to appeal the claim in writing following strict guidelines set forth in the EOB. Keep detailed records of dates, times, and names of people you speak to, and send all documents via certified mail.

Insider Information: OON charges are a nightmare with electronic claims processing because the system will automatically deny the charge (in the case of no OON benefits) or apply the OON deductible and rate without noticing that the claim was related to an emergency. The only way to process these claims correctly involves a critically thinking human who manually overrides the system to pay the claim at the INN rate. Profit-driven payers loathe paying humans to perform processes they deem automatable even when it means plan members’ pocketbooks will be harmed. They care about volume, not quality of service or ethics.

For life-threatening situations, insurance companies cannot demand that plan members adhere to INN rules. Plan members cannot be expected to waste time locating an INN ambulance provider, and ambulance providers are often required to transport patients to the nearest facility capable of providing care regardless of its network status. Insurance companies do not advertise that they are obligated to process OON charges incurred due to true emergencies at the plan member’s INN rate because they are counting on you to grumble, but not fight the erroneous charges. When you don’t balk, they win big because the burden of higher costs rests with you, the plan member, not them. If you balk with confidence and perseverance, they will eventually capitulate.

*When you appeal, have all your documents in order and stick to the point. Gather necessary records to prove your case (e.g., a copy of the ambulance provider’s trip report and/or your emergency room evaluation showing your disposition, especially if you were admitted). Write a letter with a concise chronology of the events and make sure to emphasize that given the emergency situation, you had no control over the providers who treated you and that you expect all charges to be reprocessed at the INN rate. Be sure to include copies of all EOBs received, and if the appeal involves faxing, request confirmation of receipt, and always follow-up with an appeal in writing submitted via certified mail.

Insider Information: Insurance companies are incredibly fragmented; they are black holes. You can safely assume your information will be lost multiple times, hence the need to maintain meticulous documentation of all correspondence. Resist the temptation to digress in your appeal. Frankly, most insurance company employees could care less about the injustice of your situation, and they don’t respond to emotional pleas. They work in a profit-driven, amoral industry. The common refrain from insurance company executives is that they are not denying care, only payment, as if care and payment are mutually exclusive in our current system. The insurance company knows damn well that if it denies payment, providers are most likely not going to treat for free. They also know that most people in this situation will be unable to pay out-of-pocket, yet they wash their hands of the moral dilemma. So, save your strength, and stick to the facts. To cut through the red duct tape, ask for a medical director (an MD) to review your case.

*If your appeal is denied, you still have options. If you’re covered under a group plan through your employer and your employer is self-insured, you can appeal to your health plan administrator within your human resources department for assistance with getting your claim processed correctly.

Insider Information: It’s been my experience that when self-insured employers learn of egregious decisions like refusing to cover emergency care at the INN rate, they go to bat for their employees and complain loudly to insurance executives. After all, they’re paying the insurance company to perform all administrative duties, and they don’t take kindly to fielding complaints about poor service that waste their time and resources. When all else fails, contacting your HR department usually leads to a favorable outcome. Just make sure to reveal only as much private medical information as necessary for the particular claim you’re contesting. You don’t want to set off alarm bells with your employer that you are a liability because of increased healthcare costs, either real or perceived.

If you have an individual policy or work for an employer who is fully-insured, your options are more limited and time consuming. You can contact your employer to act as a liaison, but their effect will be minimal because they are probably a small account that has little financial clout with the insurer. And, there may not even be a human resources department to whom you can appeal. You can, however, contact your state agency responsible for regulating insurance companies and file a formal complaint, or you can reach out to your elected representatives to intervene (hopefully) on your behalf.

Clearly, these actions require Herculean effort and saintly patience, and there’s no guarantee of positive resolution. But, if you’re one who believes in principle and you have the physical and emotional strength to keep fighting, please persevere. If you live through getting your OON emergency claims paid at the INN rate, see my next post on how to get OON specialty care at INN rates when there are no INN providers in your service area. The battle continues…