I have a question about health insurance billing, on the off chance that somebody here works in the industry:
If I was hospitalized in an emergency and was taken to a non-participating provider who my insurance provider refuses to pay, am I simply SOL and personally responsible for the bill?
I was unconscious at the time and was taken to an ER, never having been given a choice of provider.
How are these situations generally handled?
Thank you for any responses 
Every insurance plan I’ve ever seen allows hospitalization anywhere in an emergency. No expert here.
I wasn’t unconscious, but I did have an emergency appendectomy in October of '07. At the wrong hospital, apparently. The bill was $16,000. The insurance company, although they declined to pay the bill, did negotiate on my behalf so that the amount I am paying (by monthly payments) is $8,000.
Most likely it depends upon the insurance provider.
In the movie Sicko, Michael Moore interviews a young lady who was also in your situation - unconscious, taken by ambulance to an out-of-network hospital. She had to pay the whole bill herself.
It really is based on your insurance carrier. All you can do is submit the claim and if they deny it see if you can’t get some relief like NinetyWt did, either with the help of the insurer or the hospital.
Somewhere in your insurance plan documentation, there ought to be information about an appeal process and/or your state insurance regulation board. If you don’t have the info handy, your insurance company (or Google) should be able to help. But count me among those who have never seen an insurance plan that didn’t allow for being treated in an out-of-network facility in a true medical emergency, which it sounds like this was.
I work in medical billing.
The rules regarding emergency treatment can be arcane, and may vary from state to state. As far as I know, the ER of the hospital is required to provide treatment only to the degree necessary to stabilize your condition — that is, they’ll put a cast on your broken arm, but they won’t do follow-up treatments or physical therapy.
As far as what your insurance carrier will pay … well, the best person to ask that question of is your insurance carrier, and even then the answer may be muddy. They might give you a line like, “we’ll pay 100% of the allowable amount for all medically necessary procedures,” which in insurance-talk might mean “nothing at all, if our experts don’t agree that your procedure was necessary.” They might be willing to fork over for basic exams and treatment, but balk at pricier alternatives: eg, they’ll pay for an old-fashioned probe-up-the-butt colonoscopy, but refuse to pay for the new-fangled CT colonoscopy.
In my experience, there aren’t many cases that leap to mind of an insurance carrier flatly denying any coverage for an ER visit, but nothing they do surprises me any more.
Obligatory anecdote: one patient I spoke to went into the hospital for abdominal surgery and was non-ambulatory for 5 days afterward. When he was able, he had an MRI as follow-up, which insurance denied, saying he should’ve had it within 3 days of the operation in order to qualify.
As others said, this is going to vary by state and by insurance company. The following is anecdotal.
We used to have an HMO, the name I won’t mention, but it has a big rock as its logo.
My husband was referred (at my insistence) by our primary care MD for an angiogram for diagnosis of chest pains to a hospital and doctor that were not among the limited list of HMO members. The test revealed that he was a time bomb about to explode, with most of his main coronary artery blocked. He was operated on within hours.
I did the necessary and informed the HMO immediately that he was undergoing emergency surgery. They said fine, no further action needed. Weeks later they refused to pay for services after the first 24 hours, saying he should have called and been transferred to another hospital at that time. I went thoroughly bonkers on them. He had still been on life support! Unconscious! You told me I didn’t need to do anything! Short version of the story is it took two years of appeals to get it sorted out, but they ended up paying the entire bill.
I learned a valuable lesson: Anytime you send any document to an insurance company, send it with a return receipt option so you can prove they got it.
Also, the first rule of any insurance company related to any claim out of the ordinary is “deny it.”