True emergency? Woman with Covered California plan dealing with $33,000 hospital bill

06/20/2014 4:55 PM

06/20/2014 4:56 PM

The Affordable Care Act, signed into law in 2010, put health insurance within reach of millions of Americans. But we still have an insurance-based health system and all of those rules apply to consumers.

Nick Bavaro, owner of Bavaro Benefit Plans of Modesto, is working with a client who received a $33,000 bill after going to Memorial Medical Center with a diabetic emergency in March. She has the silver Anthem Blue Cross plan through Covered California, the state’s insurance exchange under the Affordable Care Act.

Bavaro said Anthem rejected the claim because Memorial is not in the provider network of the client’s health plan. Insurers are required to cover emergency care for enrollees whether the care was provided at a hospital inside or outside the network. But Anthem apparently needed more details to show it was a true emergency.

The 56-year-old woman, a business owner and diabetic, said her blood sugar was a dangerously high 650 milligrams per deciliter. She was vomiting. She couldn’t walk and was confused. Her daughter drove her to the hospital closest to home. She received good treatment at Memorial for three days and was discharged, she said.

Her newly acquired insurance so far hasn’t covered the whopping bills that came in the mail. She was talking about filing for bankruptcy when she brought her troubles to Bavaro’s office. “The best talker wins in these situations and I’m not a talker,” she said.

Bavaro questioned why the hospital did not transfer his client to Doctors Medical Center once she was stabilized. Doctors is within her health plan’s network. After a number of phone calls, Anthem ultimately said it needed proof it was a medical emergency. More calls were made. More time elapsed and more bills came in the mail.

On Thursday, a billing employee called her and said paperwork on her hospital care would be sent to Anthem. I’m not sure if that resulted from the work of Bavaro’s office or an email from The Modesto Bee asking the hospital about the bill.

This kind of dispute occurred before federal health reform. But here’s the message: People who are now insured, perhaps for the first time in years, will need to stay on top of their insurance claims. A recent gripe about Covered California health plans is confusion over their provider networks. It’s often not clear which physicians or medical facilities are in-network and which are not.

“We used to see this about once a year, but since the beginning of the year, we have seen it five or six times,” said Michael Colombo, an agent for Bavaro Benefits. “They go to the doctor and the doctor’s office assumes the patient has the same insurance card. When the claim is processed, they are turned down. It turns out the doctor doesn’t accept the plan.”

A resource is available for people caught in disputes.

Marta Green, spokeswoman for the state Department of Managed Health Care, said a consumer first needs to file a complaint with the insurer if the claim is denied. If the insurer still denies payment, the person can request an independent medical review from DMHC. The agency handles complaints regarding other health plan issues and medical services, not just emergency care.

Green said independent clinicians will decide whether it was an emergency and notify the health plan and consumer of their decision. “If an enrollee reasonably believes that he or she has an emergency medical condition, then the health plan is obligated to pay for the emergency medical services,” Green said.

Another issue is whether the hospital asks the patient’s health plan for authorization of further care after the person is stabilized by emergency care. The plan must respond to the hospital’s request in 30 minutes or the care is deemed authorized, Green said.

The DMHC help center can assist people with applying for an independent review. Call (888) 466-2219.

Darrel Ng, an Anthem spokesman, said he could not comment on the Modesto woman’s claim. “For Anthem to appropriately adjudicate a claim, a hospital must provide information relating to the treatment and the stay. It sounds like the hospital admits it did not provide adequate information so Anthem could determine the legitimacy of the claim.”

Memorial Spokeswoman Catherine Larsen said “it’s not unusual for health plans to deny claims. There are appeals processes in place for both patients and providers when that happens. Insurance claims can be complicated and lengthy processes.”

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