Humana denied payment for emergency room

Did the hospital also include coding for Crohn's disease since the doctor said it was likely a Crohn's flare? I would think that coding for active Crohn's should work with the dehydration.

Also, what does your policy say about going to the ER? Does it only pay if you are admitted? My insurance has a hefty co-pay for ER visits if not admitted; if admitted, no copay. Read the coverage carefully. It would have to clearly state that they won't pay for certain diagnoses. It has to give you fair warning.

I'm suffering from weakness from just seeing the ER bill. How does the hospital get away with charging $4000 for one night's stay (presumably no more than that), two bags of fluid, and a blood test? I'd expect 5-star luxury hotel accommodation and helicopter transportation to and from the hospital for that kind of money: NHS, get on it.

But seriously, I hope you get that insane charge overturned. You have diagnosed Crohn's, isn't there a code for a Crohn's flare-up like Ides suggested? Could your GI phone up on your behalf? It's so wrong that patients have to deal with this kind of financial stress on top of being sick that I don't really know what to say.

I'd call the hospital back and try to see if there's someone else in the billing department you can speak to. Or when you call insurance, continue to ask for supervisors and move up the chain that way.

pmedic said...
Believe it or not, I was only in the emergency room for 3 hours. This charge doesn't even include the ER Dr charges. That will be coming along shortly. It is highway
robbery. I doubt my GI will be able to help because according to the rude woman from the hospital, only the ER Dr can change the codes. It is disgusting and disheartening.

Gone from feeling weak to feeling like weeping. Seriously, I am just lost for words. I could understand a charge of a few hundred dollars (though I would think even that was excessive), but a few thousand dollars for a 3-hour stay. It beggars belief...

I'm not familiar with ER charges - I suppose it varies massively from hospital to hospital and insurance company to insurance company - but that charge seems like a travesty of justice. I would fight it tooth and nail; as wrong as it is you have to do that, I would still do it. And then afterwards... sue the hospital for emotional distress? =/

Doormouse, I told my husband the same thing about the stress of this is going to put me in the hospital. And you can bet it won't be the same hospital with the rude billing woman!
You would think the insurance company would get that stressing out a Crohnnie will cost the much more in the long run bc they are making us sicker! Thank you for that tip. I think this hospital has patient advocates so maybe they can help. I will try your suggestion this week.

I thought I had it bad when they made me pay 20% instead of 10% a few months ago for my ER visit. They also said it wasn't necessary. I was also dehydrated and had a super migraine. Gotta love what they feel is necessary and what isn't. Since when is dehydration no big deal?

I hope you get get this figured out. I'm not even wanting to think about what my hospital bills from this past week are going to come to.

I never really got them to pay at the higher rate. It was all in the what the hospital said unfortunately, they didn't deem it as necessary. Even though I really think dehydration should be necessary. Luckily they did pay 80% of the bill. I was stuck with I think $800 of it.

Ok, I know the process for this for California inside and out, since I used to work for the CA HMO Regulator. I see you are not CA so some of this may be different in your state. If you have not yet, call Humana and ask to file an appeal. You can also use the word "grievance." Typically, the Plan has a specific amount of time in which to investigate and respond to appeals/grievances/complaints (all three words mean the same thing, but sometimes, you have to say all three before a Call Center Agent 'gets' what you want!) If they continue to deny your emergency care, you would then need to contact the LA State Dept of Insurance. I looked it up real quick and they take complaints and have a nice insrtuctional pdf here: http://www.ldi.la.gov/consumers/misc_pubs/HowToFileAnInsuranceComplaint.pdf

Follow the directions and submit a complaint. See what happens, in California, it's not legal to deny Emergency care (note, depending on your particular coverage, you could still be subject to insane copays/deductibles and other charges, but to flat out deny, is not legal.) Emergency care validity is generally based on what's called the "Prudent Lay-person Standard." The questions that must be answered is "would a prudent lay-person reasonably believe that their condition, if left untreated, would constitute an emergency health situation?" In terms of CD and D and dehydration, the answer is usually yes, meaning the Plan has to provide coverage in accordance with your benefits.

File a complaint, and file it soon as there are generally timelines regarding complaints which must be followed. This is outrageous; health plans have a habit of denying things for non-valid reasons (I've seen so many cases where the person reviewing the claim and making a coverage decision was just plain not paying attention at best and a complete moron at worst) because a lot of people don't know about their appeal rights and/or are too sick/tired/whatever to fight.

If at the end of all this, the claims continue to be denied, you can work out payment arrangements with the hospital or sometimes, depending on your financial situation, the hospital will write off the charges. This would be a last resort. Good luck, and let me know if there's anything else I can help with!

Oh I agree if you can handle your dehydration at home, that's the best way to do it! But for me dehydration usually means I'm not able to keep any fluids down. I sip and it comes right back up, that's when it's ER time sadly. That is what they said was unnecessary.

Notcreative-Thanks for the information! I am in Louisiana. I will be filing an appeal but it is so frustrating to be the sickest you have ever felt in your life and are literally fighting for your life and now have to fight an insurance company. So maddening! Thanks again for the info!

Ncot and Jen- I tried so hard not to go to the ER. As some of you know, I am a paramedic of 20 years so I actually gave myself several IV's over the course of that week to avoid going in but I kept getting worse so I gave in and went to the ER. I didn't have vomiting but when I would go from laying flat to sitting then standing upright, my blood pressure would vary widely by 30 mm/hgwhich meant profound dehydration, at least in my case. I was urinating clear because I was drinking tons of water but I was losing it so fast and wasn't absorbing it properly. My colon is about shot, I think.

Ncot- thanks again! I think I need to move to the UK. I won't hold my breath for the US to pass a decent healthcare plan like what you have. It is a political hot potato here and each political party uses lies and misinformation to prevent us from ever getting a much needed change from what we have now. Thank again for your support!!

Scifi- yes, at least that is what the ER Dr told me. I had told him I was drinking about 3 litres at day or more and he said that with my crohns I wasn't absorbing properly. The Dr ordered the orthostatic blood pressure test, which I failed miserably. So, you body is not weird at all! Did they test your blood pressure to see if it fluctuated when laying, sitting and standing? The next time you are in the hospital and they say they don't think you are dehydrated, ask them for that test.

I am glad I am able to start my own IV too but as I get older, it gets harder, lol.

about the bill, I did get an automated phone call from Humana today saying that I should be receiving something in the mail regarding my claim. The lady I spoke to at Humana on Friday is supposed to call me tomorrow too so I am hoping she can help me and if not, I will start the formal appeal process then.
Ugh.

Many thanks to you and all the great people on healingwell for always being there and understanding when we are at our lowest point...

Sci-fi, thanks! Yes, that urine is a dead give away.

I will work on this bill issue in the morning! I am praying that tomorrow will bring good news. My patience with this bill is wearing thin and am worried I may go redneck on them, haha.