I hate insurance companies

This is going to be kind of a mild rant, both because I am too depressed to really work up a good head of steam, and also because the lady we’ve been dealing with at the insurance company has actually been very nice and reasonable. It’s just not helping that much.

Anyway, back on February 17, young Whatsit Jr. was admitted to the infant ICU of Children’s Hospital with what we thought was just a bad head cold, but turned out to be RSV and bacterial pneumonia. The pneumonia was caused by methicillin-resistant staph. He wound up on a ventilator for a week and had a chest tube in for a week after that. His total hospital stay was three weeks.

The bills for this have just started coming in. I have insurance both for myself and him, and our deductible is $1500, so I thought that’s the maximum we’d have to pay. Ha. Ha, ha, ha. It is to laugh.

It turns out that, according to Children’s, there is a shortage of pediatric specialists in this area right now, so they contract out to bring in outside traveling doctors. (I’m explaining this to the best of my ability; my understanding is somewhat murky.) These outside doctors, while incredibly good at what they do, are not covered in my insurance company’s network. Therefore my insurance company does not fully cover whatever they charge; they just cover what they (the insurance company) deems to be “reasonable”, or the going rate. In Whatsit Jr.'s case, the difference between what they deemed reasonable and what we were actually charged is $3000. Yes, 3K. Three thousand big ones.

I asked the insurance people how it is that we can be charged $1500 above and beyond our deductible, and they shrugged (yes, I could hear this over the phone) and said that’s just the way it is.

Right now, the nice and very reasonable insurance lady that I’ve been in contact with is calling Children’s and her supervisor to see if Children’s will be willing to drop the excess charges beyond what the insurance company will cover, but I’m not optimistic.

So much for getting our finances under control and moving into a nicer place. I think we’re going to be stuck in this tiny one-bedroom shack (with a three-month-old baby, no less) for a long time. I can’t even describe how much this sucks. (I guess I just gave it the ol’ college try, but it sucks so much more than I am able to convey with my limited verbal abilities.)

#*()##) insurance.

I guess I’m confused. You bought an insurance policy. You read the policy declarations. Your child needed medical care from a doctor that was not covered by your insurer. The insurer paid the hospital monies in accordance with the policy you hold. You feel they should have paid in excess of the policy you hold. Why would they have done that?

There is health insurance you can buy for pretty much every eventuality out there. It’s damned expensive, for good reason. One of the bad things about the whole managed care system is that not everything gets covered. The good thing is that more people can actually afford insurance. It’s good care for the greatest amount of people. Unfortunately, they can’t cover everything we’d like them to cover.

Sounds like you’re really in an unpleasant spot, and I’m sorry for that. But I don’t see how this is the insurace company’s fault.

In every managed care plan that I’ve ever been covered under, all hospital stays required approval by the insurance provider either prior to admission or shortly after (with 48 hours or so) of an emergency admission. If MsWhatsit’s insurance company approved this hospital stay for her son in an approved (i.e. participating) hospital, I don’t think that it was unreasonable for her to expect that the doctors providing care at this hospital were also participating providers.

It’s not like MsWhatsit specifically sought out the services of the doctor’s treating her son while he was in the hospital. The way she describes it, the doctors providing services were those apparently on staff and available at the time her son was hospitalized. If they were not, in fact, participating providers, I would think that at the very least, the hospital/doctors were obligated to inform her of that fact prior to rendering treatment.

MsWhatsit, if the hospital isn’t willing to accept your insurance provider’s “usual” covered amounts for the services provided, there may be services that are available to assist in covering non-reimbursed medical expenses from the social service agencies in your area. I know that when a co-worker of mine was hit for a large medical bill for an emergency hysterectomy, there was a foundation that helped her pick up half of her non-covered balance. There may be similar services or opportunities in your area, and it never hurts to ask.

Good luck. :slight_smile:

MsWhatsit, before you give up hope, this (considering my past jobs, employers, and various other bull) has happened to me, more than a few times. In every case where this has been an issue with Mini2U, payment, charges over the “reasonable and customary” charges per the insurance company, and insurance companies negotiating, I’ve NEVER ONCE had a problem with the charges being negotiated down.

There might be light at the end of the tunnel, so don’t give up hope! :slight_smile:

**Jadis[/b[ said:

I buy this. But the rant wasn’t directed at the hospital that failed to inform her that an out-of-network physician would be treating her child. It was directed at the insurance company who failed to pay a bill for uncovered services. That’s what I don’t get. I still fail to see how the insurance company failed to do something it was supposed to in this situation.

Thanks, Missy2U, that does make me feel marginally better.

Regarding my insurance policy, Jadis is correct in that my insurance company did approve Whatsit Jr.'s hospital stay in the first few days of his admission, and I had no reason to believe that any of his doctors weren’t covered as well. I don’t think it’s reasonable to expect a parent (or patient) to ask every doctor who comes into contact with her son during his hospital stay, “Excuse me, are you a covered provider under my insurance plan?” If we’d made a decision to have him treated by a doctor that we knew wasn’t covered under the plan, I’d have no problem with the insurance charging me for that. But that’s not what happened; we took him to the hospital, his stay there was covered, and then several weeks later we find out that some of his doctors there weren’t covered under the plan. To me, that’s just not right.

MsWhatsit said:

I don’t think this is reasonable, either. Nor do I think it is reasonable for the insurance company to oversee this, and vet every doctor that you might see. I think you should be told by the person in charge of your care (which is not your insurance company) about these issues. Every doctor I have seen (or hospital employees, if I’m in the hospital) has been very aware of the limits of my insurance. In fact, most doctors in a practice have a specific employee just for dealing with insurance companies. Your insurer was more than willing to cover you within the limits of your policy. Just as you would expect your doctor to inform you if there was not a generic equivalent to a drug you were prescribed, rather than your insurer, I would expect them to inform you they were using an out-of-network doc, and you’d be appropraitely billed.

I agree that you got screwed. I’m just arguing that you got screwed from a different direction. :slight_smile:

Well, I can see where you’re coming from, Necros. However, I’m of two minds about this: on the one hand, the hospital should have informed me that they were using out-of-network providers. On the other hand, I really think the insurance company should cover whoever happened to be working on Whatsit, Jr., no matter whether they were network providers or not, because we had no choice in who his doctors were.

I guess at this point I’m just going to hope that the insurance folks are able to renegotiate my charges with the hospital. We’ll see.

Hang in there.

I’ve been in a similar boat twice. Once, the Hospital agreed to take the insurance amount, the other time they at least lowered the amount they wanted from me. It still took two years to pay off, but at least it was lower 8-).

I’ll offer a tidbit/tale that might cheer you up a bit.

Never, ever, ever, EVER name twins with first names that start with the same letter.

My two are named Mary and Michael, and were very premature, and spent months in the hospital. They were often in the same units, and usually had the same tests performed at the same time and were seen by the same doctors at the same time. The hospital billed infants out by the first initial of their first name and their entire last name. Can you guess where we are going here?

The insurance company would get two bills for the same day, doctor, patient name, and procedure, assume the hospital accidentally double-billed them, pay one, and disallow the other one. Every damn time. For months. It took about 6 weeks for the paperwork to sift through to me. It took another week or two for me to realize what the problem was. It took another couple of weeks to convince the hospital to bill using their middle initials so the insurance company could keep them separate. Finally, that solved the problem of them just paying one of the bills. That’s right, then they paid neither of them, as they didn’t recognize them as dependents by that initial. It took about a year to finally get it all straightened out. By this time the doctors, nurses, and WE are calling them by their middle names.

Five years later, I still have to give a mini-speech every time I take a prescription to the pharmacy. “Yes, they are in your computer. But they might not be under ‘Caiti’ and ‘Ben’ like is written on the prescription, they might be under ‘Mary’ and ‘Michael’ because that is how the insurance company knows them. Or they might be under ‘Caitlin’ and ‘Bennett’ because those are their real middle names instead of what everyone calls them. Oh, the hell with it, just look them up by their birthday, will you please?”

Good luck.


jkirkman, I can see that in this day and age my parents would have never been able to get away with naming my sisters(who are non-identical twins) Janet and Joan.

My aunt would have probably rued having given birth to two of my cousins on the same date 3 years apart, as well.

I think a lot of the problem with the first-line contacts we have with our insurance companies is this tendency for companies to shop for lowest local prevailing wages rather than highest local educational standards when locating their customer service offices.
This problem is by no means restricted to just insurance companies, BTW.

I got rid of Allstate auto insurance because the billing office moved from Illinois to Texas and those ignorant hicks down there kept screwing up the bills and copping the attitude that “Nobody else ever has these complaints. What’s YOUR problem?”

Ooh, now hold on. Just a day or two ago I read something on MSN.COM, linked from their home page, about this.

Let’s see. MSN.COM. Health. Hmm. Nope. Search. Nope.

[cracking knuckles]

health.msn.com. search: “insurance cheaper die”. Nope.

tick tick tick

Ah ha! Got it! (from Google…)


In summary:

9. You don’t have to pay out-of-network charges when they’re not your fault.
There are times when you’ve played by all the HMO rules and you still wind up with a bill for out-of-network charges. But is it your responsibility to pay the doctor’s fee for an out-of-network radiologist who read your hospital X-ray because no in-network radiologist was available? No, you most certainly do not.**

Hope that’s not too much Cut&Paste for the mods. Forgive the poor lurker :slight_smile:


Fight this with the insurance company. Once you are admitted to a participating hospital by a participating doctor, your fees should be covered. I saw this happen all the time with hospital stays when I worked in insurance. You cannot control where labs are sent, what doctors are on call, anything that happens while you aren’t around. If the doctors are working with the hospital, then they are supposed to agree with the payments. If they don’t, its up to the insurance company to make good on the bill, since they approved the stay.

The problem with customer service at insurance companies is that they are not aware of the ins and outs of every policy that is sold. They have a general idea of how things are covered, but not always an idea on pre-certification, approvals, out of network exceptions for usual and customary ect.

If the insurance company gives you more shit, go to your HR deptartment. They have people who deal with insurance companies. They know the policies, and often have an inside contact at the insurer. I was one of those people who worked with HR departments, and this is a common problem.

I’m sure I don’t have to tell you (but of course I will :slight_smile: ), get a name and reference number from everyone you talk to. Not just the claim number. The reference number will be their documentation to the call. If you don’t get one, they might not mark anything in your account. Good luck!