Blue Cross won't pay emergency room doctors who saved my child's life

What is the name of your state?What is the name of your state?What is the name of your state? Georgia

My 15-yr-old son was critically injured in a sporting accident while we were in Illinois. He was air-lifted to a Level I trauma center (Carle Foundation Hospital) in Urbana, Illinois, where he underwent emergency surgery for a broken pelvis. During the 1st 36 hours, while in intensive care, we verified that the hospital was covered by our Blue Cross (Blue Choice PPO) insurance. The hospital failed to inform us that the trauma surgeons were not employed directly by the hospital and that the hospital used a lab separate from itself as well (Carle Clinic). Blue Cross originally completely denied coverage of any sort to Carle Clinic stating that they were a "non-covered provider". After an appeal, based on the fact that it was a life-threatening emergency, they agreed (in writing) that they would supply coverage for charges incurred at Carle Clinic. The total bill is appr. $20,000. However, Blue Cross is paying "usual and customary charges" that are amounting to only roughly 20- to 30% of each charge. My questions are:

1) Is it legal for Blue Cross to apply "usual and customary" to a life-threatening accidental injury?

2) In the calculation of "usual and customary", does Blue Cross have to take into account that this was a Level I trauma center and that trauma center average charges are higher than other hospitals?

2) Does Carle Foundation Hospital or Carle Clinic have any culpability due to the fact that we specifically asked whether or not the hospital was in our network? Were we somehow supposed to know we also had to ask what lab they were using and where their doctors were employed?

Thank you for any help you can provide.

Susan

[cbg]

1.) Unless your state law specifically says otherwise, yes it is. In my experience it's not customary, but it's legal.

2.) No.

3.) The person you spoke to did not necessarily know each and every facility that was going to be used - or even which were going to be necessary - or whether they were going to be inside or outside facilities. You asked if the hospital was a covered facility - they answered. They are not obligated to guess at what other facilities might need to be utilized and provide the network status of each of them.

As nice as it would be to have it otherwise, neither the hospital nor Blue Cross Blue Shield can require that all employees and all facilities used by the hospital be part of the same network. If a surgeon or a laboratory chooses not to participate, they have that right. I promise you that BCBS would love it if they could require everyone to be in-network.

I'm not unsympathetic to your situation, but I can't see where either the hospital or BCBS has violated any laws.

The only thing I can suggest is that you check with your state insurance commission as to whether there are any state or local laws that apply, or whether there might be any programs available that might help.

[rmet4nzkx]

If this sporting accident was a sanctioned event by an organization, there may be other insurance coverage available.