What is the name of your state? NJ
We recently had a baby delivered at a NJ hospital that was out of network with our insurance, not knowingly to us. However, prior to our visit, we were told by a hospital employee that the hospital would be covered by our insurance, which we acted on. Now we are being balance billed at out of network rates for the rest. Part of our bill is being treated as in network for co-insurance due to labor being treated as an emergency, however the inpatient stay is not. Also, our insurance is an employer self-funded policy, and did not opt in to the NJ Balance Billing laws, see link https://legiscan.com/NJ/text/A2039/id/1810417.
1. Is there anything, including legal action, we can leverage against the hospital to not balance bill us given they told us the hospital would be covered as in network? I realize this is our responsibility to find out, but they also shouldn't be advising us on this if they have a vested interest.
2. Our insurance did say we can appeal to them since we were told bad info by the hospital. If we appeal and are successful, the insurance company could cover it as in network (higher co-insurance on the out of network rates) or cover higher amounts of the customary costs per billing code. While a nice outcome, I'm skeptical that the insurance company is going to right the wrongs of the hospital.
3. Also, given the labor was treated as an emergency, can we also appeal to the insurance company that the rest of the stay and the baby were from the emergency labor and should be covered in the same way (ie in-network)?
4. Are there any other points to exhaust? Potentially appealing to my NY based employer given the plan is self-funded and not opting into NJ protection laws? Or entering into an arbitration with the state (https://njpicpa.maximus.com/njportal/public/c32QA.xhtml#Q19)?
Appreciate the help
We recently had a baby delivered at a NJ hospital that was out of network with our insurance, not knowingly to us. However, prior to our visit, we were told by a hospital employee that the hospital would be covered by our insurance, which we acted on. Now we are being balance billed at out of network rates for the rest. Part of our bill is being treated as in network for co-insurance due to labor being treated as an emergency, however the inpatient stay is not. Also, our insurance is an employer self-funded policy, and did not opt in to the NJ Balance Billing laws, see link https://legiscan.com/NJ/text/A2039/id/1810417.
1. Is there anything, including legal action, we can leverage against the hospital to not balance bill us given they told us the hospital would be covered as in network? I realize this is our responsibility to find out, but they also shouldn't be advising us on this if they have a vested interest.
2. Our insurance did say we can appeal to them since we were told bad info by the hospital. If we appeal and are successful, the insurance company could cover it as in network (higher co-insurance on the out of network rates) or cover higher amounts of the customary costs per billing code. While a nice outcome, I'm skeptical that the insurance company is going to right the wrongs of the hospital.
3. Also, given the labor was treated as an emergency, can we also appeal to the insurance company that the rest of the stay and the baby were from the emergency labor and should be covered in the same way (ie in-network)?
4. Are there any other points to exhaust? Potentially appealing to my NY based employer given the plan is self-funded and not opting into NJ protection laws? Or entering into an arbitration with the state (https://njpicpa.maximus.com/njportal/public/c32QA.xhtml#Q19)?
Appreciate the help