Seeking Advice on Health Insurance Claim, etc.

[hoosiergal]

What is the name of your state? First off, I reside in Indiana.

Here is my situation:

Our son, age 1.5, was taken to what I'd call an urgent care facility. After all, it states "XXX Immediate Care" for the name of the facility.

It was an urgent situation.

I discovered that he had a (2nd) ear infection, and antibiotics were prescribed.

I didn't bother to tell the girl behind the receptionist's desk, "Hey, make sure you bill this as an urgent care situation" because I figured that is HOW they bill!

Well, I thought I'd take it upon myself to keep an eye on the claim, as I wasn't getting any EOB's (explanation of benefits) forms via regular mail, and I found out from viewing this claim online thru our health insurance carrier that the claim was basically being rejected. Not only this, they had incorrectly put down that our son had previously seen this doctor before, when he had not.

I had already paid our co-pay at the time of the visit, which was $50, and I have made more than one phone call to the immediate care facility and to the hospital that does the billing for them.

I was told by a gal in the billing dept. @ that hospital that they bill more than one way. It's either a 'clinic' visit or 'urgent' visit.
When I last talked to her a while back (I documented our phone conversations, too because I typed it up in Microsoft Word afterwards), she gave me the impression that things were going to get 'solved' correctly.

However, late last week, we FINALLY get billed for the $55 balance from the hospital that does the billing. I tried contacting the person that I talked to previously, but she didn't come on the line right away, so I was forced to talk to someone else.

When I briefly explained my situation to her, she wasn't cooperative and said that 'it would be fraud' if they'd try to bill it as anything other than this 'clinic visit' stuff. I even told THEM on more than one occasion that people don't GO to urgent care facilities for regular 'ole doctor visits! The reason (in my opinion) that people go there is, of course, for urgent situations that need immediate attention.

I am reluctantly planning to pay the balance of $55, as I'm not really in the mood to deal with an ongoing claim. I didn't check with our ins. co. to see if this dr. was contracted, but I didn't know WHAT doctor would be on duty, etc., so I couldn't help that part of it.

Our ins. co. didn't show any listing for this immediate care facility, either. If we use an urgent care facility (and it has to be billed as such for the ins. co. to pay their portion of it) or use an ER, then we're only responsible for a co-pay.

They put on the bill, "Your acct. is past due." Well, it didn't get here until 2+ months after the fact, so it's not MY fault!

I probably could appeal it throu our ins. co., but they cannot 'make' the urgent care center change the way they bill things. However, I think this is very unfair, and I would like some objective advice and/or opinions and would like to know if anyone else has had dealt with a similar situation.

I was going to attach a not-so-nice and to-the point letter to stick in the envelope to give 'em a piece of my mind. Do you think this is a waste of my time. The ins. co. doesn't seem to be involved anymore at this point in the game.

TIA,

Hoosier

 

[ellencee]

hoosiergal

I'm willing to help you think this through, so I need some clarification just to make sure I understand exactly what issues you are 'contesting'.

What day of the week did you take your child? What time of day or night?

What, in your opinion, made this 'urgent' rather than something that could have been considered not urgent? ie--what was his temperature? what was he able to eat or drink? what symptoms was he showing? (pulling at his ear--that type of symptom)

Does your child have a regular physician that you could have called instead of going to the Urgent Care facility?

Are you saying that if an emergency situation existed, then your insurance would have paid all but the co-pay, but since the urgent care center did not document the visit as an emergency, the insurance is not paying the difference BECAUSE it is a non-approved facility?

FYI--urgent care centers, emergency rooms, and trauma centers are daily used as clinics--sometimes it is necessary for an indigent person to go to a facility like this in order to receive medical or health care; some people go these facilities for any after-hour situation instead of calling the doctor first. Therefore, these facilities do indeed have the right to bill as a 'clinic' visit or an 'emergency visit'.

(if this has typos, I apologize--I seem to be unable to type or spell recently)

 

[hoosiergal]

To Ellencee...

Ellencee:

I forgot to mention that we had a new family doc pending. My son's 1st appt. w/her (well-baby checkup) hadn't taken place yet. I couldn't get him in to see her, either. They wouldn't see him--he hadn't become established as a patient yet.

I don't think I noticed his ears being red, etc., but he was obviously in a distressed state, and I felt that it was urgent and that he needed to be looked at to determine the source of his agitation. It was obvious that the lil guy didn't feel good.

I took him there in the late afternoon hours.

Our ins. co. told me via telephone that the billing was being classfied as a regular visit/said they needed the proper coding for urgent visits, but it never took place, as you can see.

I understand that they can classify visits as they choose, but do you think they should've told me outright, "Hey we bill as a clinic visit, not urgent," even though this place would appear to be an urgent care center?

Do you perceive urgent and immediate care centers to mean the same thing?

Do you think it'd be pointless to send a note with the bill, or maybe my letter will get the attention of someone higher up?

I had to take our son to a local ER three days after that date (3/20/02) cause he wasn't getting any better. Come to find out, the ear infection had escalated--the medication was NOT working, he had oral thrush, and he also had herpangina.

That claim for the ER got processed correctly.

For future reference, I'll take my kids to the children's hospital in a nearby city cause that hospital IS contracted, and I heard they're excellent folks to deal with over there. They see kids day in and day out.

Thanks for your response. =)

 

[ellencee]

hoosiergal
I do think they should have told you that it would be billed as a clinic visit and not as an urgent visit, but it would have been after your son had been examined that the determination would have been made, so really you wouldn't have gained anything.

The facility can bill as either as it provides both services.

I'd be stomping my feet if the second visit hadn't been treated as an urgent or emergency visit. Apparently your son met the criteria for urgent billing on the second visit and the billing was appropriately received.

All billing procedures and the codes are uniform. That facility doesn't bill any differently or use any different critera than the next place.

It probably would be pointless to send a letter unless the purpose of the letter would be to suggest that at the time the admission, each person be told that depending on the physical findings, the charges may be billed as clinic visit and not urgent. A posted notice at the desk would even help.

Your son was without a physician to call or to see, so as a mother you did the right thing by taking him to be examined. The facility classified and billed appropriately. It is too bad that your insurance provider can not make a provision for situations like yours, where there was no alternative even though the situation did not classify as urgent.

I'm opposed to this 'contract' business between insurance companies and providers, so I'll not go further in that discussion; not now, anyway.

Glad your son is better and I'm sure he's worth the extra $55.

 

[hoosiergal]

Yes, cost is no obstacle when it comes to our children's well being. =)

If I do send the letter, I could put in there that they need to make patients aware how things are billed. I bet I'm not the first person to get a rude awakening, eh???

I took him to the immediate care facility once on 3/20/02 and then took him to a local ER on 3/23/02.

Stinks, doesn't it?!