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Valued Social Butterfly
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Re: Hospital and ER

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@GrahamW111870 wrote:

My Wife has Florida Blue. BlueMedicare Choice ( Regional PPO ) Medicare Advantage. She is 69 yrs


Then what did the Insurers Explanation of Benefits say as to why they refused to pay it ?

 

There could be several things in play here based on the plans Evidence of Coverage.

I found this one on page 47 ( read this whole section page 46 & 47) of the plans Evidence of Coverage - Florida Blue Medicare Choice (Regional PPO)

 

Page 47 of the Evidence of Coverage

BlueMedicareChoice will generally cover your medical care as long as: 
  • You receive your care from a provider who is eligible to provide services under Original Medicare.
  • As a member of our plan, you can receive your care from either a network provider or an out-of-network provider (for more about this, see Section 2 in this chapter).
    The providers in our network are listed in the Provider Directory
  • If you use an out-of-network provider, your share of the costs for your covered services may be higher.
    Because our plan is a Regional Preferred Provider Organization, if there isn’t a network provider available for you to see, you can go to an out-of-network provider but still pay the in-network amounts.
    Please note:
    While you can get your care from an out-of-network provider, the
    provider must be eligible to participate in Medicare. Except for emergency care, we cannot pay a provider who is not eligible to participate in Medicare. If you go to a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive. Check with your provider before receiving services to confirm that they are eligible to participate in Medicare.

Are they questioning the use of Emergency Care in this situation?

The Explanation of Benefits should say why they are denying the claim from this provider.

 

 

 
* * * * * * It’s Always Something - Roseanne Rosannadanna
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Re: Hospital and ER

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My Wife has Florida Blue. BlueMedicare Choice ( Regional PPO ) Medicare Advantage. She is 69 yrs

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Re: Hospital and ER

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You are talking about private insurance or employer coverage as opposed to Medicare or Medicaid - those rules are different depending upon the facility.

 

Yes, there are certain medical professionals that are contracted on an independent bases by hospitals - the normal ones are (P.A.R.E. providers - Pathologist, Anesthesiologist, Radiologist, ER Docs) - they may or may not take your in-network insurance BUT YOU CAN ALWAYS NEGOTIATE WITH THEM for a reduced fee, although it helps if your insurance has at least some payment for out of network providers which could be encountered.

 

Some states have passed rules and regulations about this - but again, even here it helps if your insurance has some coverage for out of network providers.  But even then if you have some sort of  employer coverage, these state laws don't help because employer group coverage is governed by federal law; not state..

 

I don't know why your wife's Oncologist would have sent her to the ER - he could have ordered an MRI and / or a CT Scan.  My late husband's Oncologist or his designate would have met us at the hospital, or call in the order, we would go have it done and then he would read the results himself if it was critical that it be done right then.  Sometimes he would consult with a Radiologist - who is expert in reviewing these test and writing a conclusion.  Then if immediate treatment was necessary, he would either do it at the hospital or at his office, depending on what needed to be done or arrange to have it done by another specialist provider.   ER docs have their own specialty - they are there to save lives in an immediate situation or quickly diagnosis injuries or life threatening conditions and then treat a person to a stable condition. 

 

Sorry, that part of your post is just a little confusing - I do not mean to question what was done or by whom.  Hope she got better.

Is your insurer rejecting the claim because it was not what they considered an "emergency"?  Or because your insurance does not have any out of network provisions?  The later (no out of network coverage) is normally reserved for HMO-type plans but I guess could be others as well.

 

As I said, you can try and negotiate a more reasonable price with the provider that was out of network.  Yes, their fees are high but remember what they do, remember they have to be there whether or not there is anybody to treat or if there are many to treat at once..  Since they are normally independent contractors or employed by an LLC or some group - they have to cover their own malpractice insurance and in a very exposed field, pay their own self employment tax, have their own health insurance coverage - you know all the things that any self-employed person has to cover.

 

It is what it is - if and until we get anything else.

 

Good luck with the negotiations.

* * * * * * It’s Always Something - Roseanne Rosannadanna
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Hospital and ER

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Be aware that even after your insurance has been verified with the Hospital the Doctor treating you in the ER may not accept your insurance. That was the case with my Wife who was referred to the ER by her Oncologist. The Doctor who arranged the MRI and the CT Scan in consultation with her Oncologist saw my Wife for ten minutes. His Fee $1,924.00 was apparently decided by an Algorithm. Florida Blue rejected the claim. The Hospital spokesperson told us the Hospital was not responsible for the Doctors in the ER. State Law apparently.

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