"not medically necessary" hospital admission

[tonymoo]

What is the name of your state (only U.S. law)? New York

I went to the ER feeling really sick with a bunch problems: headache, swelling in a few places, strange rash, sleeping 20 hours per day. In network hospital.

They were concerned about a few of them and admitted me - first time in hospital in 15+ years (not a frequent flyer). Was in hospital for 4 days and got a bunch of IV drugs and felt better and was released. Thing is, every test they ran came back negative - none of the cultures grew and nothing came back on the fungus and virus tests. Got out Saturday.

Tuesday, my insurance calls me to say they not going to pay because based on their info, the admission wasn't medically necessary.

Of course, I will appeal. Was just wondering how this typically works and what I can expect the hospital to bill me for. I know I will be billed the $200 copay no matter what. But what about the "not medically necessary" hospital admission. Is this a fight between me and insurance or does the fact it was in network make it a fight between the hospital and insurance? I tried researching NY law and it's just so complicated.

Should I expect the hospital to jump in and try to help get the claim approved or are they just going to try to bill me?

Also, at what point should I get a lawyer involved if it doesn't go well? And what kind of lawyer?

Thanks in advance.

 

[ecmst12]

Contact the hospital, they should handle the appeal, they have the medical information to do so and you do not. Especially since they are in-network, this should not be a question for them.

Check your benefits again though, I don't know if the $200 is your copay for the ER but if so, that is normally waived if you are admitted. Inpatient admissions are usually paid differently, so your responsibility if approved may be different.

When they told you that they were denying the claim, did they tell you that it would be your responsibility? If it is, you will get an EOB from them with the amount on it. But again, hopefully the appeal will be successful.

 

[tonymoo]

Thanks for your help.

I called the hospital and they said they would appeal. I don't have the EOB yet.

I also spoke to the HR guy at my company (500 people) and he spoke to his insurance contact. Neither had ever encountered such a thing (necessity based denial of an entire admission thru ER) before and both thought I wouldn't be on the hook for anything except the 200 (that's our copay for each hospital admission).

I will update when I have a final answer.

 

[ecmst12]

It could be something simple like the hospital not sending in the notes in soon enough, hopefully will be easily fixed.